Abstract: The overall risks and harms resulting from alcohol consumption have been systematically assessed and are well documented. According to the latest WHO estimates,1 alcohol consumption contributed to 3 million deaths in 2016 globally and was responsible for 5·1% of the global burden of disease and injury. Alcohol consumption is associated with an increased risk of many health conditions and is the main and sufficient cause for several disorders, including alcohol dependence, liver cirrhosis, and several other non-communicable diseases and mental health conditions.

Abstract: Healthy sleep is essential for physical and mental health, and social wellbeing; however, across the globe, and particularly in developing countries, national public health agendas rarely consider sleep health. Sleep should be promoted as an essential pillar of health, equivalent to nutrition and physical activity. To improve sleep health across the globe, a focus on education and awareness, research, and targeted public health policies are needed. We recommend developing sleep health educational programmes and awareness campaigns; increasing, standardising, and centralising data on sleep quantity and quality in every country across the globe; and developing and implementing sleep health policies across sectors of society. Efforts are needed to ensure equity and inclusivity for all people, particularly those who are most socially and economically vulnerable, and historically excluded.

Abstract:

Summary

Background

Guidelines emphasise the health benefits of bouts of physical activity of any duration. However, the associations of intermittent lifestyle physical activity accumulated through non-exercise with mortality and major adverse cardiovascular events (MACE) remain unclear. We aimed to examine the associations of bouts of moderate-to-vigorous intermittent lifestyle physical activity (MV-ILPA) and the proportion of vigorous activity contributing within these bouts with mortality and MACE.

Methods

In this prospective cohort study, we used data from the UK Biobank on adults who do not exercise (ie, those who did not report leisure-time exercise) who had wrist-worn accelerometry data available. Participants were followed up until Nov 30, 2022, with the outcome of interest of all-cause mortality obtained through linkage with NHS Digital of England and Wales, and the NHS Central Register and National Records of Scotland, and MACE obtained from inpatient hospitalisation data provided by the Hospital Episode Statistics for England, the Patient Episode Database for Wales, and the Scottish Morbidity Record for Scotland. MV-ILPA bouts were derived using a two-level Random Forest classifier and grouped as short (<1 min), medium (1 to <3 min; 3 to <5 min), and long (5 to <10 min). We further examined the dose–response relationship of the proportion of vigorous physical activity contributing to the MV-ILPA bout.

Findings

Between June 1, 2013, and Dec 23, 2015, 103 684 Biobank participants wore an accelerometer on their wrist. 25 241 adults (mean age 61·8 years [SD 7·6]), of whom 14 178 (56·2%) were women, were included in our analysis of all-cause mortality. During a mean follow-up duration of 7·9 years (SD 0·9), 824 MACE and 1111 deaths occurred. Compared with bouts of less than 1 min, mortality risk was lower for bouts of 1 min to less than 3 min (hazard ratio [HR] 0·66 [0·53–0·81]), 3 min to less than 5 min (HR 0·56 [0·46–0·69]), and 5 to less than 10 min (HR 0·48 [0·39–0·59]). Similarly, compared with bouts of less than 1 min, risk of MACE was lower for bouts of 1 min to less than 3 min (HR 0·71 [0·54–0·93]), 3 min to less than 5 min (0·62 [0·48–0·81]), and 5 min to less than 10 min (0·59 [0·46–0·76]). Short bouts (<1 min) were associated with lower MACE risk only when bouts were comprised of at least 15% vigorous activity.

Interpretation

Intermittent non-exercise physical activity was associated with lower mortality and MACE. Our results support the promotion of short intermittent bouts of non-exercise physical activity of moderate-to-vigorous intensity to improve longevity and cardiovascular health among adults who do not habitually exercise in their leisure time.

Funding

Australian National Health, Medical Research Council, and Wellcome Trust.

Abstract: BackgroundRacial and ethnic disparities in mortality persist in the US population. We studied the contribution of social determinants of health (SDoH) to racial and ethnic disparities in premature death.MethodsA nationally representative sample of individuals aged 20–74 years who participated in the US National Health and Nutrition Examination Survey (NHANES) between 1999 and 2018 were included. Self-reported SDoH (employment, family income, food security, education, access to health care, health insurance, housing instability, and being married or living with a partner) were collected in each survey cycle. Participants were categorised into four groups of race and ethnicity: Black, Hispanic, White, and other. Deaths were ascertained from linkage to the National Death Index with follow-up until 2019. Multiple mediation analysis was used to assess simultaneous contributions of each individual SDoH to racial disparities in premature all-cause mortality.FindingsWe included 48 170 NHANES participants in our analyses, consisting of 10 543 (21·9%) Black participants, 13 211 (27·4%) Hispanic participants, 19 629 (40·7%) White participants, and 4787 (9·9%) participants of other racial and ethnic groups. Mean survey-weighted age was 44·3 years (95% CI 44·0–44·6), 51·3% (50·9–51·8) of participants were women, and 48·7% (48·2–49·1) were men. 3194 deaths before age 75 years were recorded (930 Black participants, 662 Hispanic participants, 1453 White participants, and 149 other participants). Black adults had significantly higher premature mortality than other racial and ethnic groups (p<0·0001): premature death rates per 100 000 person-years were 852 (95% CI 727–1000) for Black adults, 445 (349–574) for Hispanic adults, 546 (474–630) for White adults, and 521 (336–821) for other adults. Unemployment, lower family income, food insecurity, less than high school education, no private health insurance, and not being married nor living with a partner were significantly and independently associated with premature death. Dose–response associations were observed between cumulative number of unfavourable SDoH and premature all-cause mortality: hazard ratios (HRs) were 1·93 (95% CI 1·61–2·31) for those with one unfavourable SDoH, 2·24 (1·87–2·68) for those with two, 3·98 (3·34–4·73) for those with three, 4·78 (3·98–5·74) for those with four, 6·08 (5·06–7·31) for those with five, and 7·82 (6·60–9·26) for those with six or more unfavourable SDoH (p<0·0001 for linear trend). After adjusting for SDoH, HRs for premature all-cause mortality for Black adults compared with White adults decreased from 1·59 (1·44–1·76) to 1·00 (0·91–1·10), suggesting complete mediation of this racial difference in mortality.InterpretationUnfavourable SDoH are associated with increased rates of premature death and contribute to differences between Black and White racial groups in premature all-cause mortality in the US population. Innovative public health policies and interventions targeting SDoH are needed to reduce premature deaths and health disparities in this population.FundingUS National Institutes of Health. Racial and ethnic disparities in mortality persist in the US population. We studied the contribution of social determinants of health (SDoH) to racial and ethnic disparities in premature death. A nationally representative sample of individuals aged 20–74 years who participated in the US National Health and Nutrition Examination Survey (NHANES) between 1999 and 2018 were included. Self-reported SDoH (employment, family income, food security, education, access to health care, health insurance, housing instability, and being married or living with a partner) were collected in each survey cycle. Participants were categorised into four groups of race and ethnicity: Black, Hispanic, White, and other. Deaths were ascertained from linkage to the National Death Index with follow-up until 2019. Multiple mediation analysis was used to assess simultaneous contributions of each individual SDoH to racial disparities in premature all-cause mortality. We included 48 170 NHANES participants in our analyses, consisting of 10 543 (21·9%) Black participants, 13 211 (27·4%) Hispanic participants, 19 629 (40·7%) White participants, and 4787 (9·9%) participants of other racial and ethnic groups. Mean survey-weighted age was 44·3 years (95% CI 44·0–44·6), 51·3% (50·9–51·8) of participants were women, and 48·7% (48·2–49·1) were men. 3194 deaths before age 75 years were recorded (930 Black participants, 662 Hispanic participants, 1453 White participants, and 149 other participants). Black adults had significantly higher premature mortality than other racial and ethnic groups (p<0·0001): premature death rates per 100 000 person-years were 852 (95% CI 727–1000) for Black adults, 445 (349–574) for Hispanic adults, 546 (474–630) for White adults, and 521 (336–821) for other adults. Unemployment, lower family income, food insecurity, less than high school education, no private health insurance, and not being married nor living with a partner were significantly and independently associated with premature death. Dose–response associations were observed between cumulative number of unfavourable SDoH and premature all-cause mortality: hazard ratios (HRs) were 1·93 (95% CI 1·61–2·31) for those with one unfavourable SDoH, 2·24 (1·87–2·68) for those with two, 3·98 (3·34–4·73) for those with three, 4·78 (3·98–5·74) for those with four, 6·08 (5·06–7·31) for those with five, and 7·82 (6·60–9·26) for those with six or more unfavourable SDoH (p<0·0001 for linear trend). After adjusting for SDoH, HRs for premature all-cause mortality for Black adults compared with White adults decreased from 1·59 (1·44–1·76) to 1·00 (0·91–1·10), suggesting complete mediation of this racial difference in mortality. Unfavourable SDoH are associated with increased rates of premature death and contribute to differences between Black and White racial groups in premature all-cause mortality in the US population. Innovative public health policies and interventions targeting SDoH are needed to reduce premature deaths and health disparities in this population.

Abstract: Football (soccer) players might be at increased risk of neurodegenerative disease, which has led to questions regarding the safety of the sport and recent measures introduced by football associations to reduce heading of the ball. We aimed to assess the risk of neurodegenerative disease among male football players in the Swedish top division Allsvenskan, compared with matched controls.In this cohort study, we identified all male football players (amateurs and professionals) who had played at least one game in Allsvenskan from Aug 1, 1924 to Dec 31, 2019 and excluded players whose personal identity number could not be retrieved or be identified in the Total Population Register, and those who were not born in Sweden and who had immigrated to the country after age 15 years. Football players were matched with up to ten controls from the general population according to sex, age, and region of residence. We used nationwide registers to compare the risk of neurodegenerative disease (diagnoses recorded in death certificates, during hospital admissions and outpatient visits, or use of prescription drugs for dementia) among football players versus controls. We also assessed each type of neurodegenerative disease (Alzheimer's disease and other dementias, motor neuron disease, and Parkinson's disease) separately, and compared the risk of neurodegenerative disease among outfield players versus goalkeepers.Of 7386 football players who had played at least one game in the top Swedish division between Aug 1, 1924, and Dec 31, 2019, 182 players were excluded for an unretrievable personal identity number, and 417 were excluded due to their number not being identified in the Total Population Register. After a further exclusion of 780 players and 11 627 controls who were born outside of Sweden and who had immigrated to the country after age 15 years, 6007 football players (510 goalkeepers) were included in the study population along with 56 168 matched controls. During follow-up to Dec 31, 2020, 537 (8·9%) of 6007 football players and 3485 (6·2%) of 56 168 controls were diagnosed with neurodegenerative disease. The risk of neurodegenerative disease was higher among football players than controls (hazard ratio [HR] 1·46 [95% CI 1·33-1·60]). Alzheimer's disease and other dementias were more common among football players than controls (HR 1·62 [95% CI 1·47-1·78]), significant group differences were not observed for motor neuron disease (HR 1·27 [0·73-2·22]), and Parkinson's disease was less common among football players (HR 0·68 [0·52-0·89]). The risk of neurodegenerative disease was higher for outfield players than controls (HR 1·50 [95% CI 1·36-1·65]) but not for goalkeepers versus controls (HR 1·07 [0·78-1·47]), and outfield players had a higher risk of neurodegenerative disease than did goalkeepers (HR 1·43 [1·03-1·99]). All-cause mortality was slightly lower among football players than controls (HR 0·95 [95% CI 0·91-0·99]).In this cohort study, male football players who had played in the Swedish top division had a significantly increased risk of neurodegenerative disease compared with population controls. The risk increase was observed for Alzheimer's disease and other dementias but not for other types of neurodegenerative disease, and among outfield players, but not among goalkeepers. Our study expands on the data that can be used to assess and manage risks in the sport.Karolinska Institutet, The Swedish Research Council for Sport Science, Folksam Research Foundation, Hedberg Foundation, Neurofonden, and Åhlen Foundation.

Abstract:

Summary

Cancer screening has the potential to decrease mortality from several common cancer types. The first cancer screening programme in China was initiated in 1958 and the Cancer High Incidence Fields established in the 1970s have provided an extensive source of information for national cancer screening programmes. From 2012 onwards, four ongoing national cancer screening programmes have targeted eight cancer types: cervical, breast, colorectal, lung, oesophageal, stomach, liver, and nasopharyngeal cancers. By synthesising evidence from pilot screening programmes and population-based studies for various screening tests, China has developed a series of cancer screening guidelines. Nevertheless, challenges remain for the implementation of a fully successful population-based programme. The aim of this Review is to highlight the key milestones and the current status of cancer screening in China, describe what has been achieved to date, and identify the barriers in transitioning from evidence to implementation. We also make a set of implementation recommendations on the basis of the Chinese experience, which might be useful in the establishment of cancer screening programmes in other countries.

Abstract: As the USA faces a worsening overdose crisis, improving access to evidence-based treatment for opioid use disorder (OUD) remains a policy priority. Federal regulatory changes in response to the COVID-19 pandemic substantially expanded flexibilities on take-home doses for methadone treatment for OUD. These changes have fuelled questions about the effect of new regulations on OUD outcomes and the potential effect on health of permanently integrating these flexibilities into treatment policy going forward. To aide US policy makers as they consider implementing permanent methadone regulatory changes, we conducted a review synthesising peer-reviewed research on the effect of the flexibilities of methadone take-home policies introduced during COVID-19 on methadone programme operations, OUD patient and provider experiences, and patient health outcomes. We interpret the findings in the context of the federal rule-making process and discuss avenues by which these findings can be incorporated and implemented into US policies on substance use treatment going forward.

Abstract: Mental health disorders during the post-partum period are a common morbidity, but parental leave might help alleviate symptoms by preventing or reducing stress. We aim to summarise available evidence on the effect of different types of parental leave on mental health outcomes among parents. For this systematic review, we searched Ovid MEDLINE, Web of Science, PsycINFO, CINAHL, and Scopus from database inception to Aug 29, 2022, for peer-reviewed, quantitative studies written in English. We included studies if the exposure was postnatal parental leave; a relevant comparison group was present (eg, paid vs unpaid leave); and if indicators related to general mental health, including depression, anxiety, stress, and suicide, for either parent were evaluated or recorded at any time after childbirth. The Review is registered with PROSPERO (registration number CRD42021227499). Of the 3441 records screened, 45 studies were narratively synthesised. Studies were done in high-income countries, and they examined generosity by any parental leave (n=5), benefit amount (n=13), and leave duration (n=31). 38 studies were of medium or high quality. Improved mental health was generally observed among women (referred to as mothers in this Review) with more generous parental leave policies (ie, leave duration and paid vs unpaid leave). For example, increased duration of leave was generally associated with reduced risk of poor maternal mental health, including depressive symptoms, psychological distress and burnout, and lower mental health-care uptake. However, the association between fathers' leave and paternal mental health outcomes was less conclusive as was the indirect effect of parental leave use on partners' mental health.

Abstract: Deaths by suicide remain a major public health challenge worldwide. Identifying and targeting risk factors for suicide mortality is a potential approach to prevention. We aimed to summarise current knowledge on the range and magnitude of individual-level risk factors for suicide mortality in the general population and evaluate the quality of the evidence.In this umbrella review, five bibliographic databases were systematically searched for articles published from database inception to Aug 31, 2022. We included meta-analyses of observational studies on individual-level risk factors for suicide mortality in the general population. Biological, genetic, perinatal, and ecological risk factors were beyond the scope of this study. Effect sizes were synthesised and compared across domains. To test robustness and consistency of the findings, evidence for small-study effects and excess significance bias (ie, the ratio between the overall meta-analysis effect size and that of its largest included study) was examined, and prediction intervals were calculated. Risk of bias was assessed by the Risk of Bias in Systematic Reviews instrument. The protocol was pre-registered with PROSPERO (CRD42021230119).We identified 33 meta-analyses on 38 risk factors for suicide mortality in the general population. 422 (93%) of the 454 primary studies included in the meta-analyses were from high-income countries. A previous suicide attempt and suicidal ideation emerged as strong risk factors (with effect sizes ranging from 6 to 16). Psychiatric disorders were associated with a greatly elevated risk of suicide mortality, with risk ratios in the range of 4-13. Suicide risk for physical illnesses (such as cancer and epilepsy) and sociodemographic factors (including unemployment and low education) were typically increased two-fold. Contact with the criminal justice system, state care in childhood, access to firearms, and parental death by suicide also increased the risk of suicide mortality. Among risk factors for which sex-stratified analyses were available, associations were generally similar for males and females. However, the quality of the evidence was limited by excess significance and high heterogeneity, and prediction intervals suggested poor replicability for almost two-thirds of identified risk factors.A wide range of risk factors were identified across various domains, which underscores suicide mortality as a multifactorial phenomenon. Prevention strategies that span individual and population approaches should account for the identified factors and their relative strengths. Despite the large number of risk factors investigated, few associations were supported by robust evidence. Evidence of causal inference will need to be tested in high-quality study designs.Wellcome Trust.

Abstract: There are one billion migrants globally, of whom 82 million are forced migrants. Pregnant migrants face pre-migration stressors such as conflict, transit stressors including poverty, and post-migration stressors including navigating the immigration system; these stressors can make them vulnerable to mental illness. We aimed to assess the global prevalence of and risk factors for perinatal mental health disorders or substance use among women who are migrants.In this systematic review and meta-analysis, we searched OVID MEDLINE, Embase, PsycINFO, CENTRAL, Global Health, Scopus, and Web of Science for studies published from database inception until July 8, 2022. Cohort, cross-sectional, and interventional studies with prevalence data for any mental illness in pregnancy or the postnatal period (ie, up to a year after delivery) or substance use in pregnancy were included. The primary outcome was the prevalence of perinatal common mental health disorders among women who are migrants, globally. Data for study quality and risk factors were also extracted. A random-effects meta-analysis was used to calculate pooled prevalence estimates, when appropriate. Sensitivity analyses were conducted according to study quality, sample representativeness, and method of outcome assessment. Risk factor data were synthesised narratively. This study is registered with PROSPERO, CRD42021226291.18 650 studies were retrieved, of which 135 studies comprising data from 621 995 participants met the inclusion criteria. 123 (91%) of 135 studies were conducted in high-income host countries. Five (4%) of 135 studies were interventional, 40 (30%) were cohort, and 90 (66%) were cross-sectional. The most common regions of origin of participants were South America, the Middle East, and north Africa. Only 26 studies presented disaggregated data for forced migrants or economic migrants. The pooled prevalence of perinatal depressive disorders was 24·2% (range 0·5-95·5%; I2 98·8%; τ2 0·01) among all women who are migrants, 32·5% (1·5-81·6; 98·7%; 0·01) among forced migrants, and 13·7% (4·7-35·1; 91·5%; 0·01) among economic migrants (p<0·001). The pooled prevalence of perinatal anxiety disorders was 19·6% (range 1·2-53·1; I2 96·8%; τ2 0·01) among all migrants. The pooled prevalence of perinatal post-traumatic stress disorder (PTSD) among all migrant women was 8·9% (range 3·2-33·3; I2 97·4%; τ2 0·18). The pooled prevalence of perinatal PTSD among forced migrants was 17·1% (range 6·5-44·3; I2 96·6%; τ2 0·32). Key risk factors for perinatal depression were being a recently arrived immigrant (ie, approximately within the past year), having poor social support, and having a poor relationship with one's partner.One in four women who are migrants and who are pregnant or post partum experience perinatal depression, one in five perinatal anxiety, and one in 11 perinatal PTSD. The burden of perinatal mental illness appears higher among women who are forced migrants compared with women who are economic migrants. To our knowledge, we have provided the first pooled estimate of perinatal depression and PTSD among women who are forced migrants. Interpreting the prevalence estimate should be observed with caution due to the very wide range found within the included studies. Additionally, 66% of studies were cross-sectional representing low quality evidence. These findings highlight the need for community-based routine perinatal mental health screening for migrant communities, and access to interventions that are culturally sensitive, particularly for forced migrants who might experience a higher burden of disease than economic migrants.UK National Institute for Health Research (NIHR); March of Dimes European Preterm Birth Research Centre, Imperial College; Imperial College NIHR Biomedical Research Centre; and Nuffield Department of Population Health, University of Oxford.

Abstract: With growing health risks from climate change and a trend of increasing carbon emissions from coal, it is time for China to take action. The rising frequency and severity of extreme weather events in China, such as record-high temperatures, low rainfall, severe droughts, and floods in many regions (along with the compound and ripple effects of these events on human health) have underlined the urgent need for health-centred climate action. The rebound in the country's coal consumption observed in 2022 reflected the great challenge faced by China in terms of its coal phase-down, over-riding the country's gains in reducing greenhouse gas (GHG) emissions. Timely and adequate responses will not only reduce or avoid the impacts of climate-related health hazards but can also protect essential infrastructures from disruptions caused by extreme weather. Health and climate change are inextricably linked, necessitating a high prioritisation of health in adaptation and mitigation efforts. The 2023 China report of the Lancet Countdown continues to track progress on health and climate change in China, while now also attributing the health risks of climate change to human activities and providing examples of feasible and effective climate solutions. This fourth iteration of the China report was spearheaded by the Lancet Countdown regional centre in Asia, based at Tsinghua University in Beijing, China. Progress is monitored across 28 indicators in five domains: from climate change impacts, exposures, and vulnerability (section 1); to the different elements of action, including adaption (section 2) and mitigation, and their health implications (section 3); to economics and finance (section 4); and public and political engagement (section 5). This report was compiled with the contribution of 76 experts from 26 institutions both within and outside of China. The impending global stocktake at the UN Framework Convention on Climate Change 28th Conference of the Parties (COP28), the UN initiative on early warning systems (which pledged to ensure the world was protected by the end of 2027), and China's action plans to reduce air pollutants and GHGs illustrate that global climate action has moved from talk to concrete plans. These initiatives could deliver major health benefits, but none of them explicitly list health as a policy target or indicator. The results of the global stocktake could guide health-focused and feasible interventions. The first Health Day and climate-health ministerial meeting that will be hosted at COP28 underline the trend to mainstream health in the global climate change agenda. Health risks arising from human-induced climate change, and production-based and consumption-based CO2 and ambient particulate matter (PM2·5) emissions (indicator 4.2.4) indicate the urgent need for mitigation by identifying human contributions to carbon emissions and climate change. Early warning systems for health risks (indicator 2.4) and the city-level human comfort index provide bottom-up examples of adaptation practices. The record-breaking heat and droughts of 2022 were associated with increased adverse health outcomes. Wildfire exposure increased by 54% (indicator 1.2.1) compared with the historical baseline and heatwave-related mortality increased by 342% (indicator 1.1.1). Heat-related work loss increased by 24% (indicator 1.1.2), safe outdoor physical activity loss increased by 67%, and the resulting hours available for safe outdoor activities decreased by 9·6% (indicator 1.1.3). Human-caused climate change was responsible for 49·4% of heatwave-related mortality, 30·9% of heat-related labour productivity loss, 98·8% of populations affected by drought, and 7·6% of populations affected by flood in the previous 20 years. Heat-related economic loss also broke all previous records, with costs of heat-related labour productivity loss reaching 1·91% of gross domestic product (GDP; US$313·5 billion; indicator 4.1.2). Future concerns must not be overlooked: in the case of future sea level rise, the ratio of exposed populations to the total population in coastal provinces is expected to be 7·7% in 2050 and 12·9% in 2100 under high emission scenarios (indicator 1.4)—putting these populations at risk from the hazards of coastal erosion, floods, and water and land salinification, and at risk of physical harm on coastal infrastructure. Growing capacity building to adequately respond to public health emergencies (indicator 2.1.1), expanding coverage of early warning systems (indicator 2.3), and improvements in cross-sectoral information sharing (indicator 2.2) all exemplify China's steady progress in climate change adaption, which involves responses to health risks that are imminent or have already occurred. In response to rising temperatures, use of air-conditioning increased, providing heat protection. However, this use also contributed to increased GHG emissions. Meanwhile, there was no substantial increase in urban green space coverage, which can provide sustainable cooling, while also delivering direct benefits to people's physical and mental health. Transitions in the energy system coupled with air quality control measures have considerably lowered GHG emissions and air pollution in the past 10 years. Indeed, between 2015 and 2020, improvements in PM2·5 air pollution reduction resulted in 282 400 deaths avoided, and 1·5% less CO2 was emitted in 2022 than in 2021 as a result of substantial reductions in emissions from industrial processes. However, as electricity generation from hydropower and other low-carbon energy sources was threatened by extreme weather events in 2022, coal power was used to fill the gap and secure the energy supply. Consequently, since 2011, coal consumption has grown by the second largest rate (4·3%), posing a persistent health risk related to air pollution. Hence, there is an urgent need to diversify China's energy mix and increase access to diverse sources of renewable energy as safe and stable alternatives to coal power generation. Without a health-centred focus, China risks bypassing the energy transition and getting stuck in a high-carbon entrapment. With the impacts of climate change on health becoming increasingly visible, the coverage of climate change and health grew substantially from 2021 to 2022 on Weibo and among individual users of Baidu. However, engagement from professional channels such as newspapers, academic journals, and government websites on the climate change–health nexus has remained practically unchanged over the past 2 years, and health was rarely mentioned or prioritised in current mitigation and adaptation actions. Current early warning systems are mainly based on meteorological signals, such as extreme heat, ignoring health implications. Although there is a health section in the National Adaptation Strategy 2035, the absence of a stand-alone nationwide health adaptation strategy exposed the low priority of health in the country's adaptation agenda. Meanwhile, the ratio of public engagement (media, academic, and government) on climate and health to public engagement on climate-only items has grown very slowly over the past 20 years, also implying the low prioritisation of health by the public climate change agenda. Since the first report in 2020, the China reports of the Lancet Countdown have been taking stock of progress on climate change and health and reporting findings that have helped to inform and accelerate further policy progress. Issues around climate change and health have been increasingly prominent in relevant policies at both national, regional, and sectoral levels, such as the climate content in health policies such as the annual working priorities of Healthy China. However, overall progress has so far been poor. Therefore, we present five evidence-informed policy recommendations to harness opportunities to deliver a safer, healthy future for people in China: Investing in renewable energy infrastructure can reduce GHG emissions and promote energy diversity and resilience. Research and development efforts on grid integration and energy storage can enhance the efficacy, reliability, and affordability of renewable technologies, making them more accessible for widespread adoption. By prioritising these investments, China can cut its long-term reliance on coal power, and pave the way for a cleaner, more sustainable energy system that mitigates climate change and fosters a healthier environment for present and future generations. By capitalising on the interconnections between carbon reduction and improved air quality, China can protect human health, enhance environmental wellbeing, and build resilient communities for generations to come. Transitioning to cleaner and renewable energy sources, promoting energy efficiency in all sectors, and implementing sustainable transportation systems are all components of this strategy. In addition, imposing stringent emission standards for industries, promoting reforestation and conservation actions, and promoting sustainable agricultural practices all contribute to the reduction of carbon emissions and air pollutants. China should develop a population health-oriented meteorological early warning system that accounts for climate health hazards. Such a system will enable the issuing of warnings when climate characteristics or conditions have health concerns and the implementation of targeted and preventive actions for these concerns. Creating an advanced early warning system that provides comprehensive protection for the health of vulnerable populations, such as older people, children, pregnant women, and patients suffering from chronic diseases, can help reduce the toll of climate-related hazards in China. Characterising the interconnected and complex nature of extreme weather events, such as heatwaves, floods, and cyclones can help inform health-protective mechanisms targeted at protecting vulnerable populations, crucial infrastructure, and ecosystems susceptible to cascading climate effects. In addition, charaterising the interactions between sectors such as water, energy, or agriculture and health enables the development of comprehensive response strategies. There is a need for empirical research on the health effects of response strategies such as enhanced early warning systems, improved infrastructure resilience, community preparedness and response plans, and the implementation of nature-based solutions. By promoting relevant research, China can increase its understanding of the compound and cascading effects of extreme weather events and develop effective strategies to mitigate their effects, safeguard lives, and nurture resilient societies. These guidelines should provide specific recommendations and strategies for various stakeholders, including local governments, health-care systems, communities, and individuals. Local governments can launch local health adaptation plans and vulnerability maps that reflect local contexts. Health-care systems should develop protocols and training programmes to enhance their capacity to respond to climate-related health challenges. Communities can be empowered through education and awareness campaigns that promote climate-resilient practices and the protection of vulnerable populations. Individuals can be provided with practical guidance on adapting their lifestyles to reduce the health risks associated with climate change. By tailoring guidelines to different actors, China can foster a coordinated and comprehensive approach to health adaptation, ensuring the wellbeing and resilience of communities in the face of a changing climate. 2023 is a crucial moment; the Lancet Countdown's stocktake on health and climate change helps identify and define opportunities for accelerated climate action. Looking back at the causes and impacts of climate change in China highlights the need for urgently accelerating mitigation and adaptation efforts. Extreme weather events are stifling mitigation work, and a positive reaction to climate change will enable China to speed up mitigation measures, lead the zero-carbon transition, and deliver immediate health benefits to its people.

Abstract:

Summary

Background

Dementia incidence declined in many high-income countries in the 2000s, but evidence on the post-2010 trend is scarce. We aimed to analyse the temporal trend in England and Wales between 2002 and 2019, considering bias and non-linearity.

Methods

Population-based panel data representing adults aged 50 years and older from the English Longitudinal Study of Ageing were linked to the mortality register across wave 1 (2002–03) to wave 9 (2018–19) (90 073 person observations). Standard criteria based on cognitive and functional impairment were used to ascertain incident dementia. Crude incidence rates were determined in seven overlapping initially dementia-free subcohorts each followed up for 4 years (ie, 2002–06, 2004–08, 2006–10, 2008–12, 2010–14, 2012–16, and 2014–18). We examined the temporal trend of dementia incidence according to age, sex, and educational attainment. We estimated the trend of dementia incidence adjusted by age and sex with Cox proportional hazards and multistate models. Restricted cubic splines allowed for potential non-linearity in the time trend. A Markov model was used to project future dementia burden considering the estimated incidence trend.

Findings

Incidence rate standardised by age and sex declined from 2002 to 2010 (from 10·7 to 8·6 per 1000 person-years), then increased from 2010 to 2019 (from 8·6 to 11·3 per 1000 person-years). Adjusting for age and sex, and accounting for missing dementia cases due to death, estimated dementia incidence declined by 28·8% from 2002 to 2008 (incidence rate ratio 0·71, 95% CI 0·58–0·88), and increased by 25·2% from 2008 to 2016 (1·25, 1·03–1·54). The group with lower educational attainment had a smaller decline in dementia incidence from 2002 to 2008 and a greater increase after 2008. If the upward incidence trend continued, there would be 1·7 million (1·62–1·75) dementia cases in England and Wales by 2040, 70% more than previously forecast.

Interpretation

Dementia incidence might no longer be declining in England and Wales. If the upward trend since 2008 continues, along with population ageing, the burden on health and social care will be large.

Funding

UK Economic and Social Research Council.

Abstract: A comprehensive understanding of temporal trends in the disease burden in Australia is lacking, and these trends are required to inform health service planning and improve population health. We explored the burden and trends of diseases and their risk factors in Australia from 1990 to 2019 through a comprehensive analysis of the Global Burden of Disease Study (GBD) 2019.In this systematic analysis for GBD 2019, we estimated all-cause mortality using the standardised GBD methodology. Data sources included primarily vital registration systems with additional data from sample registrations, censuses, surveys, surveillance, registries, and verbal autopsies. A composite measure of health loss caused by fatal and non-fatal disease burden (disability-adjusted life-years [DALYs]) was calculated as the sum of years of life lost (YLLs) and years of life lived with disability (YLDs). Comparisons between Australia and 14 other high-income countries were made.Life expectancy at birth in Australia improved from 77·0 years (95% uncertainty interval [UI] 76·9-77·1) in 1990 to 82·9 years (82·7-83·1) in 2019. Between 1990 and 2019, the age-standardised death rate decreased from 637·7 deaths (95% UI 634·1-641·3) to 389·2 deaths (381·4-397·6) per 100 000 population. In 2019, non-communicable diseases remained the major cause of mortality in Australia, accounting for 90·9% (95% UI 90·4-91·9) of total deaths, followed by injuries (5·7%, 5·3-6·1) and communicable, maternal, neonatal, and nutritional diseases (3·3%, 2·9-3·7). Ischaemic heart disease, self-harm, tracheal, bronchus, and lung cancer, stroke, and colorectal cancer were the leading causes of YLLs. The leading causes of YLDs were low back pain, depressive disorders, other musculoskeletal diseases, falls, and anxiety disorders. The leading risk factors for DALYs were high BMI, smoking, high blood pressure, high fasting plasma glucose, and drug use. Between 1990 and 2019, all-cause DALYs decreased by 24·6% (95% UI 21·5-28·1). Relative to similar countries, Australia's ranking improved for age-standardised death rates and life expectancy at birth but not for YLDs and YLLs between 1990 and 2019.An important challenge for Australia is to address the health needs of people with non-communicable diseases. The health systems must be prepared to address the increasing demands of non-communicable diseases and ageing.Bill & Melinda Gates Foundation.

Abstract: Although loneliness and social isolation have been linked to an increased risk of non-communicable diseases such as cardiovascular disease and dementia, their association with the risk of severe infection is uncertain. We aimed to examine the associations between loneliness and social isolation and the risk of hospital-treated infections using data from two independent cohort studies.We assessed the association between loneliness and social isolation and incident hospital-treated infections using data for participants from the UK Biobank study aged 38-73 years at baseline and participants from the nationwide population-based Finnish Health and Social Support (HeSSup) study aged 20-54 years at baseline. For inclusion in the study, participants had to be linked to national health registries, have no history of hospital-treated infections at or before baseline, and have complete data on loneliness or social isolation. Participants with missing data on hospital-treated infections, loneliness, and social isolation were excluded from both cohorts. The outcome was defined as a hospital admission with a primary diagnosis of infection, ascertained via linkage to electronic health records.After exclusion of 8·6 million participants for not responding or not providing appropriate consent, the UK Biobank cohort consisted of 456 905 participants (249 586 women and 207 319 men). 26 860 (6·2%) of 436 001 participants with available data were reported as being lonely and 40 428 (9·0%) of 448 114 participants with available data were socially isolated. During a median 8·9 years (IQR 8·0-9·6) of follow-up, 51 361 participants were admitted to hospital due to an infectious disease. After adjustment for age, sex, demographic and lifestyle factors, and morbidities, loneliness was associated with an increased risk of a hospital-treated infection (hazard ratio [HR] 1·12 [95% CI 1·07-1·16]), whereas social isolation was not (HR 1·01 [95% CI 0·97-1·04]). Of 64 797 individuals in the HeSSup cohort, 18 468 (11 367 women and 7101 men) were eligible for inclusion. 4466 (24·4%) of 18 296 were lonely and 1776 (9·7%) of 18 376 socially isolated. During a median follow-up of 10·0 years (IQR 10·0-10·1), 814 (4·4%) participants were admitted to hospital for an infectious disease. The HRs for the HeSSup study replicated those in the UK Biobank (multivariable-adjusted HR for loneliness 1·32 [95% CI 1·06-1·64]; 1·08 [0·87-1·35] for social isolation).Loneliness might increase susceptibility to severe infections, although the magnitude of this effect appears modest and residual confounding cannot be excluded. Interventional studies are required before policy recommendations can advance.Academy of Finland, the UK Medical Research Council, and Wellcome Trust UK.

Abstract: Urban green and blue spaces (UGBS) have the potential to improve public health and wellbeing, address health inequities, and provide co-benefits for the environment, economy, and society. To achieve these ambitions, researchers should engage with communities, practitioners, and policy makers in a virtuous circle of research, policy, implementation, and active citizenship using the principles of co-design, co-implementation, co-evaluation, and co-translation. This Viewpoint provides an integrated perspective on the challenges that hinder the delivery of health-enhancing UGBS and recommendations to address them. Our recommendations include: strengthening the evidence beyond cross-sectional research designs, strengthening the evidence base on UGBS intervention approaches, evaluating the effects on diverse population groups and communities, addressing inequities in the distribution and quality of UGBS, accelerating research on blue space, providing evidence for environmental effects, incorporating co-design approaches, developing innovative modelling methods, fostering whole-system evidence, harnessing political drivers, creating collaborations for sustainable UGBS action, and advancing evidence in low-income and middle-income countries. The full potential of UGBS as public health, social, economic, and environmental assets is yet to be realised. Acting on the research and translation recommendations will aid in addressing these challenges in collaboration with research, policy, practice, and communities.

Abstract: BackgroundOut-of-hospital cardiac arrest (OHCA) is an important global public health issue, but its epidemiology and outcomes in low-income and middle-income countries remain largely unknown. We aim to comprehensively describe the incidence, process of care, and outcomes of OHCA in China.MethodsIn the prospective, multicentre, population-based Baseline Investigation of Out-of-hospital Cardiac Arrest (BASIC-OHCA) registry study, participating sites were selected from both urban and rural areas in all seven geographical regions across China. All patients with OHCA assessed by emergency medical service (EMS) staff were consecutively enrolled from Aug 1, 2019, to Dec 31, 2020. Patients with suspected cardiac arrest assessed by bystanders whose return of spontaneous circulation was achieved without the need for defibrillation or EMS personnel cardiopulmonary resuscitation were excluded. Patients with all key variables missing were excluded, including resuscitation attempt, age, sex, witnessed status, cause, all process of care indicators, and all outcome measures. In this analysis, we included data for EMS agencies serving 25 monitoring sites (20 urban and five rural) that included the entire serving population, data for the whole of 2020, and at least 50 OHCA patients in 2020. Data were collected and reported using the Utstein template. We calculated the crude incidence of EMS-assessed OHCA in 2020. We also report data on baseline characteristics (including sex, cause, location of OHCA, and presence of shockable rhythm), process of care (including EMS response time, cardiopulmonary resuscitation, defibrillation, and advanced life support), and outcomes of non-traumatic OHCA between Aug 1, 2019, and Dec 31, 2020, including survival and survival with favourable neurological outcomes at discharge or 30 days, and at 6 and 12 months.FindingsOf 115·1 million people served by the 25 participating sites, 132 262 EMS-assessed patients with OHCA were enrolled, and resuscitation was attempted for 42 054 (31·8%) patients between Aug 1, 2019, and Dec 31, 2020. The crude incidence of EMS-assessed OHCA was 95·7 per 100 000 population (95% CI 95·6–95·8) in 2020. Among 38 227 individuals with non-traumatic OHCA, 25 958 (67·9%) were male, 30 282 (79·2%) had a cardiac arrest at home, 32 523 (85·1%) had a presumed cardiac cause, and 2297 (6·0%) presented with an initial shockable rhythm. 4049 (11·5%) of 35 090 patients with an unwitnessed or bystander-witnessed OHCA received dispatcher-assisted cardiopulmonary resuscitation and 7121 (20·3%) received bystander cardiopulmonary resuscitation; only 14 (<0·1%) patients were assessed by bystanders with an automated external defibrillator. The median EMS response time was 12 min (IQR 9–16). At hospital discharge or 30 days, 441 (1·2%) of 38 227 survived, 304 (0·8%) survived up to 6 months, and 269 (0·7%) up to 12 months. At hospital discharge or 30 days, 309 (0·8%) survived with favourable neurological outcomes, 257 (0·7%) had favourable neurological outcomes at 6 months, and 236 (0·6%) at 12 months.InterpretationOur findings revealed a high burden of EMS-assessed OHCA with a low proportion of resuscitation attempts. The suboptimal implementation of chain of survival and unsatisfactory prognosis call for national efforts to improve the care and outcomes of patients with OHCA in China.FundingThe National Science & Technology Fundamental Resources Investigation Program of China, the State Key Program of the National Natural Science Foundation of China, Taishan Pandeng Scholar Program of Shandong Province, the Key Research & Development Program of Shandong Province, the Interdisciplinary Young Researcher Groups Program of Shandong University, the Clinical Research Center of Shandong University, the ECCM Program of Clinical Research Center of Shandong University, and the Natural Science Foundation of Shandong Province.

Abstract: Childhood maltreatment is associated with adverse health outcomes and this risk can be transmitted to the next generation. We aimed to investigate the association between exposure to maternal childhood maltreatment and common childhood physical and mental health problems, neurodevelopmental disorders, and related comorbidity patterns in offspring.We conducted a retrospective cohort study using data from the Environmental influences on Child Health Outcomes (ECHO) Program, which was launched to investigate the influence of early life exposures on child health and development in 69 cohorts across the USA. Eligible mother-child dyads were those with available data on maternal childhood maltreatment exposure and at least one child health outcome measure (autism spectrum disorder, attention-deficit hyperactivity disorder [ADHD], internalising problems, obesity, allergy, and asthma diagnoses). Maternal history of childhood maltreatment was obtained retrospectively from the Adverse Childhood Experiences or Life Stressor Checklist questionnaires. We derived the prevalence of the specified child health outcome measures in offspring across childhood and adolescence by harmonising caregiver reports and other relevant sources (such as medical records) across cohorts. Child internalising symptoms were assessed using the Child Behavior Checklist. Associations between maternal childhood maltreatment and childhood health outcomes were measured using a series of mixed-effects logistic regression models. Covariates included child sex (male or female), race, and ethnicity; maternal and paternal age; maternal education; combined annual household income; maternal diagnosis of depression, asthma, ADHD, allergy, or autism spectrum disorder; and maternal obesity. Two latent class analyses were conducted: to characterise patterns of comorbidity of child health outcomes; and to characterise patterns of co-occurrence of childhood maltreatment subtypes. We then investigated the association between latent class membership and maternal childhood maltreatment and child health outcomes, respectively.Our sample included 4337 mother-child dyads from 21 longitudinal cohorts (with data collection initiated between 1999 and 2016). Of 3954 mothers in the study, 1742 (44%) had experienced exposure to abuse or neglect during their childhood. After adjustment for confounding, mothers who experienced childhood maltreatment were more likely to have children with internalising problems in the clinical range (odds ratio [OR] 2·70 [95% CI 1·95-3·72], p<0·0001), autism spectrum disorder (1·70 [1·13-2·55], p=0·01), ADHD (2·09 [1·63-2·67], p<0·0001), and asthma (1·54 [1·34-1·77], p<0·0001). In female offspring, maternal childhood maltreatment was associated with a higher prevalence of obesity (1·69 [1·17-2·44], p=0·005). Children of mothers exposed to childhood maltreatment were more likely to exhibit a diagnostic pattern characterised by higher risk for multimorbidity. Exposure to multiple forms of maltreatment across all subtypes of maternal childhood maltreatment was associated with the highest risk increases for most offspring health outcomes, suggesting a dose-response relationship.Our findings suggest that maternal childhood maltreatment experiences can be a risk factor for disease susceptibility in offspring across a variety of outcomes and emphasise the need for policies focusing on breaking the intergenerational transmission of adversity.Environmental influences on Child Health Outcomes Program, Office of the Director, National Institutes of Health.

Abstract:

Summary

Background

Genetic variants that affect alcohol use in East Asian populations could help assess the causal effects of alcohol consumption on cause-specific mortality. We aimed to investigate the associations between alcohol intake and cause-specific mortality using conventional and genetic epidemiological methods among more than 512 000 adults in China.

Methods

The prospective China Kadoorie Biobank cohort study enrolled 512 724 adults (210 205 men and 302 519 women) aged 30–79 years, during 2004–08. Residents with no major disabilities from ten diverse urban and rural areas of China were invited to participate, and alcohol use was self-reported. During 12 years of follow-up, 56 550 deaths were recorded through linkage to death registries, including 23 457 deaths among 168 050 participants genotyped for ALDH2-rs671 and ADH1B-rs1229984. Adjusted hazard ratios (HRs) for cause-specific mortality by self-reported and genotype-predicted alcohol intake were estimated using Cox regression.

Findings

33% of men drank alcohol most weeks. In conventional observational analyses, ex-drinkers, non-drinkers, and heavy drinkers had higher risks of death from most major causes than moderate drinkers. Among current drinkers, each 100 g/week higher alcohol intake was associated with higher mortality risks from cancers (HR 1·18 [95% CI 1·14−1·22]), cardiovascular disease (CVD; HR 1·19 [1·15−1·24]), liver diseases (HR 1·51 [1·27−1·78]), non-medical causes (HR 1·15 [1·08−1·23]), and all causes (HR 1·18 [1·15−1·20]). In men, ALDH2-rs671 and ADH1B-rs1229984 genotypes predicted 60-fold differences in mean alcohol intake (4 g/week in the lowest group vs 255 g/week in the highest). Genotype-predicted alcohol intake was uniformly and positively associated with risks of death from all causes (n=12 939; HR 1·07 [95% CI 1·05−1·10]) and from pre-defined alcohol-related cancers (n=1274; 1·12 [1·04−1·21]), liver diseases (n=110; 1·31 [1·02−1·69]), and CVD (n=6109; 1·15 [1·10−1·19]), chiefly due to stroke (n=3285; 1·18 [1·12–1·24]) rather than ischaemic heart disease (n=2363; 1·06 [0·99–1·14]). Results were largely consistent using a polygenic score to predict alcohol intake, with higher intakes associated with higher risks of death from alcohol-related cancers, CVD, and all causes. Approximately 2% of women were current drinkers, and although power was low to assess observational associations of alcohol with mortality, the genetic evidence suggested that the excess risks in men were due to alcohol, not pleiotropy.

Interpretation

Higher alcohol intake increased the risks of death overall and from major diseases for men in China. There was no genetic evidence of protection from moderate drinking for all-cause and cause-specific mortality, including CVD.

Funding

Kadoorie Charitable Foundation, National Natural Science Foundation of China, British Heart Foundation, Cancer Research UK, GlaxoSmithKline, Wellcome Trust, Medical Research Council, and Chinese Ministry of Science and Technology.

Abstract: Effectiveness of non-pharmaceutical interventions (NPIs), such as school closures and stay-at-home orders, during the COVID-19 pandemic has been assessed in many studies. Such assessments can inform public health policies and contribute to evidence-based choices of NPIs during subsequent waves or future epidemics. However, methodological issues and no standardised assessment practices have restricted the practical value of the existing evidence. Here, we present and discuss lessons learned from the COVID-19 pandemic and make recommendations for standardising and improving assessment, data collection, and modelling. These recommendations could contribute to reliable and policy-relevant assessments of the effectiveness of NPIs during future epidemics.

Abstract: BackgroundPeople who are incarcerated are at high risk of developing tuberculosis. We aimed to estimate the annual global, regional, and national incidence of tuberculosis among incarcerated populations from 2000 to 2019.MethodsWe collected and aggregated data for tuberculosis incidence and prevalence estimates among incarcerated individuals in published and unpublished literature, annual tuberculosis notifications among incarcerated individuals at the country level, and the annual number of incarcerated individuals at the country level. We developed a joint hierarchical Bayesian meta-regression framework to simultaneously model tuberculosis incidence, notifications, and prevalence from 2000 to 2019. Using this model, we estimated trends in absolute tuberculosis incidence and notifications, the incidence and notification rates, and the case detection ratio by year, country, region, and globally.FindingsIn 2019, we estimated a total of 125 105 (95% credible interval [CrI] 93 736–165 318) incident tuberculosis cases among incarcerated individuals globally. The estimated incidence rate per 100 000 person-years overall was 1148 (95% CrI 860–1517) but varied greatly by WHO region, from 793 (95% CrI 430–1342) in the Eastern Mediterranean region to 2242 (1515–3216) in the African region. Global incidence per 100 000 person-years between 2000 and 2012 among incarcerated individuals decreased from 1884 (95% CrI 1394–2616) to 1205 (910–1615); however, from 2013 onwards, tuberculosis incidence per 100 000 person-years was stable, from 1183 (95% CrI 876–1596) in 2013 to 1148 (860–1517) in 2019. In 2019, the global case detection ratio was estimated to be 53% (95% CrI 42–64), the lowest over the study period.InterpretationOur estimates suggest a high tuberculosis incidence rate among incarcerated individuals globally with large gaps in tuberculosis case detection. Tuberculosis in incarcerated populations must be addressed with interventions specifically tailored to improve diagnoses and prevent transmission as a part of the broader global tuberculosis control effort.FundingNational Institutes of Health. People who are incarcerated are at high risk of developing tuberculosis. We aimed to estimate the annual global, regional, and national incidence of tuberculosis among incarcerated populations from 2000 to 2019. We collected and aggregated data for tuberculosis incidence and prevalence estimates among incarcerated individuals in published and unpublished literature, annual tuberculosis notifications among incarcerated individuals at the country level, and the annual number of incarcerated individuals at the country level. We developed a joint hierarchical Bayesian meta-regression framework to simultaneously model tuberculosis incidence, notifications, and prevalence from 2000 to 2019. Using this model, we estimated trends in absolute tuberculosis incidence and notifications, the incidence and notification rates, and the case detection ratio by year, country, region, and globally. In 2019, we estimated a total of 125 105 (95% credible interval [CrI] 93 736–165 318) incident tuberculosis cases among incarcerated individuals globally. The estimated incidence rate per 100 000 person-years overall was 1148 (95% CrI 860–1517) but varied greatly by WHO region, from 793 (95% CrI 430–1342) in the Eastern Mediterranean region to 2242 (1515–3216) in the African region. Global incidence per 100 000 person-years between 2000 and 2012 among incarcerated individuals decreased from 1884 (95% CrI 1394–2616) to 1205 (910–1615); however, from 2013 onwards, tuberculosis incidence per 100 000 person-years was stable, from 1183 (95% CrI 876–1596) in 2013 to 1148 (860–1517) in 2019. In 2019, the global case detection ratio was estimated to be 53% (95% CrI 42–64), the lowest over the study period. Our estimates suggest a high tuberculosis incidence rate among incarcerated individuals globally with large gaps in tuberculosis case detection. Tuberculosis in incarcerated populations must be addressed with interventions specifically tailored to improve diagnoses and prevent transmission as a part of the broader global tuberculosis control effort.

Abstract: Although general practice can contribute to reducing health inequalities, existing evidence provides little guidance on how this reduction can be achieved. We reviewed interventions influencing health and care inequalities in general practice and developed an action framework for health professionals and decision makers. We conducted a realist review by searching MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Cochrane Library for systematic reviews of interventions into health inequality in general practice. We then screened the studies in the included systematic reviews for those that reported their outcomes by socioeconomic status or other PROGRESS-Plus (Cochrane Equity Methods Group) categories. 159 studies were included in the evidence synthesis. Robust evidence on the effect of general practice on health inequalities is scarce. Focusing on common qualities of interventions, we found that to reduce health inequalities, general practice needs to be informed by five key principles: involving coordinated services across the system (ie, connected), accounting for differences within patient groups (ie, intersectional), making allowances for different patient needs and preferences (ie, flexible), integrating patient worldviews and cultural references (ie, inclusive), and engaging communities with service design and delivery (ie, community-centred). Future work should explore how these principles can inform the organisational development of general practice. Although general practice can contribute to reducing health inequalities, existing evidence provides little guidance on how this reduction can be achieved. We reviewed interventions influencing health and care inequalities in general practice and developed an action framework for health professionals and decision makers. We conducted a realist review by searching MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Cochrane Library for systematic reviews of interventions into health inequality in general practice. We then screened the studies in the included systematic reviews for those that reported their outcomes by socioeconomic status or other PROGRESS-Plus (Cochrane Equity Methods Group) categories. 159 studies were included in the evidence synthesis. Robust evidence on the effect of general practice on health inequalities is scarce. Focusing on common qualities of interventions, we found that to reduce health inequalities, general practice needs to be informed by five key principles: involving coordinated services across the system (ie, connected), accounting for differences within patient groups (ie, intersectional), making allowances for different patient needs and preferences (ie, flexible), integrating patient worldviews and cultural references (ie, inclusive), and engaging communities with service design and delivery (ie, community-centred). Future work should explore how these principles can inform the organisational development of general practice. Inequalities in health are “systematic differences in health between different socioeconomic groups within a society. As they are socially produced, they are potentially avoidable and widely considered unacceptable in a civilised society.”1Whitehead M A typology of actions to tackle social inequalities in health.J Epidemiol Community Health. 2007; 61: 473-478Crossref PubMed Scopus (216) Google Scholar Although these differences are driven by inequalities in the wider social determinants of health, which shape our circumstances from before our birth and during the life course,2Dahlgren G Whitehead M The Dahlgren-Whitehead model of health determinants: 30 years on and still chasing rainbows.Public Health. 2021; 199: 20-24Crossref PubMed Scopus (58) Google Scholar health-care services have a substantial role to play.3NHS EnglandCore20PLUS5 (adults)—an approach to reducing healthcare inequalities 2021.https://www.england.nhs.uk/about/equality/equality-hub/national-healthcare-inequalities-improvement-programme/core20plus5/Date: Nov 1, 2021Date accessed: March 29, 2023Google Scholar General practitioners especially can mitigate the effect of social determinants of health because they deal with the psychosocial aspects of patients’ health.4Starfield B Primary care: an increasingly important contributor to effectiveness, equity, and efficiency of health services. SESPAS report 2012.Gac Sanit. 2012; 26: 20-26Crossref PubMed Scopus (220) Google Scholar, 5Maguire D Buck D Inequalities in life expectancy—changes over time and implications for policy. King's Fund, London2015Google Scholar, 6Exworthy M Morcillo V Primary care doctors' understandings of and strategies to tackle health inequalities: a qualitative study.Prim Health Care Res Dev. 2019; 20: e20Crossref PubMed Scopus (6) Google Scholar, 7Allen M Allen J Hogarth SMM Working for health equity: the role of health professionals. UCL Institute of Health Equity, London2013Crossref Google Scholar However, inequalities in health and health care are often intertwined.8Ford J Sowden S Olivera J et al.Transforming health systems to reduce health inequalities.Future Healthc J. 2021; 8: e204-e209Crossref PubMed Google Scholar, 9Hart JT The inverse care law.Lancet. 1971; 1: 405-412Summary PubMed Scopus (2208) Google Scholar For example, in the UK, general practices in the most deprived areas have 2·5 days less general practitioner time per week compared with their counterparts in the least deprived areas.10Ford J Nussbaum C Primary care workforce inequalities remain as wide as ever.https://www.phpc.cam.ac.uk/pcu/research/research-groups/crmh/research/crmh-health-inequalities/primary-care-workforce-inequalities-remain-as-wide-as-ever/Date: Nov 4, 2022Date accessed: March 29, 2023Google Scholar In such practices, patient experience is worse and the identification and management of long-term conditions, such as hypertension, is generally more challenging11Wu AS Dodhia H Whitney D Ashworth M Is the rule of halves still relevant today? A cross-sectional analysis of hypertension detection, treatment and control in an urban community.J Hypertens. 2019; 37: 2470-2480Crossref PubMed Scopus (0) Google Scholar, 12Curtis HJ Walker AJ MacKenna B Croker R Goldacre B Prescription of suboptimal statin treatment regimens: a retrospective cohort study of trends and variation in English primary care.Br J Gen Pract. 2020; 70: e525-e533Crossref PubMed Scopus (0) Google Scholar because of increased multimorbidity and risk factors.13Head A Fleming K Kypridemos C Schofield P Pearson-Stuttard J O'Flaherty M Inequalities in incident and prevalent multimorbidity in England, 2004–19: a population-based, descriptive study.Lancet Healthy Longev. 2021; 2: e489-e497Summary Full Text Full Text PDF PubMed Google Scholar Evidence for what is effective at reducing inequalities in health and health care in general practice is inconclusive.14Arblaster L Lambert M Entwistle V et al.A systematic review of the effectiveness of health service interventions aimed at reducing inequalities in health.J Health Serv Res Policy. 1996; 1: 93-103Crossref PubMed Scopus (101) Google Scholar A systematic review of the evidence on health-service interventions that can reduce inequalities in health showed that successful interventions include a systematic, intensive, and multidisciplinary approach, enhanced access, the utilisation of services, tailoring to patient needs, and community involvement.14Arblaster L Lambert M Entwistle V et al.A systematic review of the effectiveness of health service interventions aimed at reducing inequalities in health.J Health Serv Res Policy. 1996; 1: 93-103Crossref PubMed Scopus (101) Google Scholar Additional evidence indicates that shared decision making in primary care might reduce socioeconomic inequalities by particularly benefiting disadvantaged groups through increased knowledge, informed choice, and participation.15Durand M-A Carpenter L Dolan H et al.Do interventions designed to support shared decision-making reduce health inequalities? A systematic review and meta-analysis.PLoS One. 2014; 9e94670Crossref Scopus (300) Google Scholar On the contrary, primary prevention for cardiovascular disease that is focused only on individuals at high risk has been found to increase socioeconomic inequalities in health and care outcomes.16Capewell S Graham H Will cardiovascular disease prevention widen health inequalities?.PLoS Med. 2010; 7e1000320Crossref PubMed Scopus (232) Google Scholar Studies on general-practice interventions have been unable to establish the differential effect of such interventions across multiple interacting aspects of disadvantage and rarely interrogate the role of structural and systemic factors.17Attwood S van Sluijs E Sutton S Exploring equity in primary-care-based physical activity interventions using PROGRESS-Plus: a systematic review and evidence synthesis.Int J Behav Nutr Phys Act. 2016; 13: 60Crossref PubMed Scopus (36) Google Scholar, 18Terens N Vecchi S Bargagli AM et al.Quality improvement strategies at primary care level to reduce inequalities in diabetes care: an equity-oriented systematic review.BMC Endocr Disord. 2018; 18: 31Crossref PubMed Scopus (9) Google Scholar, 19Scott-Samuel A Smith KE Fantasy paradigms of health inequalities: utopian thinking?.Soc Theory Health. 2015; 13: 418-436Crossref Scopus (41) Google Scholar, 20Gkiouleka A Huijts T Beckfield J Bambra C Understanding the micro and macro politics of health: inequalities, intersectionality & institutions—a research agenda.Soc Sci Med. 2018; 200: 92-98Crossref PubMed Scopus (154) Google Scholar Most of the evidence comes from controlled trials that do not address the effect of the social determinants of health.14Arblaster L Lambert M Entwistle V et al.A systematic review of the effectiveness of health service interventions aimed at reducing inequalities in health.J Health Serv Res Policy. 1996; 1: 93-103Crossref PubMed Scopus (101) Google Scholar, 15Durand M-A Carpenter L Dolan H et al.Do interventions designed to support shared decision-making reduce health inequalities? A systematic review and meta-analysis.PLoS One. 2014; 9e94670Crossref Scopus (300) Google Scholar, 16Capewell S Graham H Will cardiovascular disease prevention widen health inequalities?.PLoS Med. 2010; 7e1000320Crossref PubMed Scopus (232) Google Scholar However, inequalities in health and health care are produced across multiple interacting dimensions beyond socioeconomic status (eg, gender and ethnicity) and are contingent on structural factors, such as policies on housing, the labour market, or education.20Gkiouleka A Huijts T Beckfield J Bambra C Understanding the micro and macro politics of health: inequalities, intersectionality & institutions—a research agenda.Soc Sci Med. 2018; 200: 92-98Crossref PubMed Scopus (154) Google Scholar Therefore, there will not be a one-size-fits-all solution. Still, general practitioners are left with little guidance on how to address health inequalities driven by structural factors.1Whitehead M A typology of actions to tackle social inequalities in health.J Epidemiol Community Health. 2007; 61: 473-478Crossref PubMed Scopus (216) Google Scholar, 6Exworthy M Morcillo V Primary care doctors' understandings of and strategies to tackle health inequalities: a qualitative study.Prim Health Care Res Dev. 2019; 20: e20Crossref PubMed Scopus (6) Google Scholar, 21Nussbaum C Massou E Fisher R Morciano M Harmer R Ford J Inequalities in the distribution of the general practice workforce in England: a practice-level longitudinal analysis.BJGP Open. 2021; 5 (BJGPO.2021.0066.)Crossref PubMed Scopus (16) Google Scholar Researchers and policy makers should prioritise identifying the principles of equitable health-care services that will be achievable, not despite social determinants of health, but rather by addressing them. To identify such principles, we synthesised the evidence on interventions and routine care in general practice that decrease or increase inequalities in health and health care and, on the basis of this evidence, we produced an action framework for health-care professionals and decision makers. The Review was guided by evidence on cardiovascular disease, cancer, diabetes, or chronic obstructive pulmonary disease or their risk factors, as the main drivers of inequalities in life expectancy.22Waterall J Health matters: preventing cardiovascular disease. Public Health England, London2019Google Scholar We adopted a definition of health inequalities that includes social inequalities in health outcomes (eg, morbidity) and health care at the patient level (eg, access) and system level (eg, funding).8Ford J Sowden S Olivera J et al.Transforming health systems to reduce health inequalities.Future Healthc J. 2021; 8: e204-e209Crossref PubMed Google Scholar Our conceptual framework put the social determinants of health at the centre of the analysis, allowing us to draw on theories that suggest that health inequalities result from the unequal distribution of social determinants of health, which in turn result from economic and political structures23Raphael D A discourse analysis of the social determinants of health.Crit Public Health. 2011; 21: 221-236Crossref Scopus (0) Google Scholar and inequalities in power.23Raphael D A discourse analysis of the social determinants of health.Crit Public Health. 2011; 21: 221-236Crossref Scopus (0) Google Scholar, 24Babbel B Mackenzie M Hastings A Watt G How do general practitioners understand health inequalities and do their professional roles offer scope for mitigation? Constructions derived from the deep end of primary care.Crit Public Health. 2017; 29: 168-180Crossref Scopus (22) Google Scholar, 25Brassolotto J Raphael D Baldeo N Epistemological barriers to addressing the social determinants of health among public health professionals in Ontario, Canada: a qualitative inquiry.Crit Public Health. 2014; 24: 321-336Crossref Scopus (56) Google Scholar Adopting an intersectional understanding of power20Gkiouleka A Huijts T Beckfield J Bambra C Understanding the micro and macro politics of health: inequalities, intersectionality & institutions—a research agenda.Soc Sci Med. 2018; 200: 92-98Crossref PubMed Scopus (154) Google Scholar, 26Crenshaw K Mapping the margins: identity politics, intersectionality, and violence against women.Stanford Law Rev. 1991; 43: 1241-1299Crossref Google Scholar, 27Collins PH The difference that power makes: intersectionality and participatory democracy.in: Hankivsky O Jordan-Zachery JS The Palgrave handbook of intersectionality in public policy. Palgrave Macmillan, London2019: 167-192Crossref Google Scholar, 28Collins PH Bilge S Intersectionality. Polity Press, Cambridge2020Google Scholar enabled us to approach health inequalities as the outcome of multiple disadvantages or privileges that people experience simultaneously according to their socioeconomic position, gender, race, ethnicity, sexuality, disability, and other identities.20Gkiouleka A Huijts T Beckfield J Bambra C Understanding the micro and macro politics of health: inequalities, intersectionality & institutions—a research agenda.Soc Sci Med. 2018; 200: 92-98Crossref PubMed Scopus (154) Google Scholar, 29Weber L Parra-Medina D Intersectionality and women's health: charting a path to eliminating health disparities. Gender perspectives on health and medicine. Emerald Group Publishing, Bingley2003Google Scholar Intersectionality offered us a theoretical tool to capture the ways that interventions and care can increase or decrease inequalities by having a differential effect on individuals according to their circumstances. Because of this approach we were able to interrogate the effect of both universal and targeted interventions on health inequalities within and between groups.30Rose GA Khaw K-T Marmot M Rose's strategy of preventive medicine: the complete original text. Oxford University Press, Oxford2008Crossref Google Scholar We integrated Collins’ framework of power organisation27Collins PH The difference that power makes: intersectionality and participatory democracy.in: Hankivsky O Jordan-Zachery JS The Palgrave handbook of intersectionality in public policy. Palgrave Macmillan, London2019: 167-192Crossref Google Scholar, 28Collins PH Bilge S Intersectionality. Polity Press, Cambridge2020Google Scholar to organise inequalities in general practice across four domains: structural (ie, policies and institutional structures), cultural (ie, beliefs about inequalities, their causes, and solutions), disciplinary (ie, organisational practices emerging whenever a policy or programme is implemented), and interpersonal (ie, personal experiences and relationships). Finally, we built on Levitas’ theory of utopia as a method31Levitas R Utopia as method: the imaginary reconstitution of society. Palgrave Macmillan, London2013Crossref Scopus (430) Google Scholar and fantasy paradigms in health inequalities19Scott-Samuel A Smith KE Fantasy paradigms of health inequalities: utopian thinking?.Soc Theory Health. 2015; 13: 418-436Crossref Scopus (41) Google Scholar to imagine what equitable general practice looks like and identify relevant guiding principles. We conducted a realist review32Wong G Greenhalgh T Westhorp G Buckingham J Pawson R RAMESES publication standards: realist syntheses.BMC Med. 2013; 11: 21Crossref PubMed Scopus (626) Google Scholar based on Pawson and colleagues’33Pawson R Greenhalgh T Harvey G Walshe K Realist review—a new method of systematic review designed for complex policy interventions.J Health Serv Res Policy. 2005; 10: 21-34Crossref PubMed Scopus (1666) Google Scholar five iterative steps (appendix p 1): (1) locating existing theories; (2) searching for evidence; (3) selecting articles; (4) extracting and organising data; and (5) narratively synthesising the evidence, combining steps 3 and 4 to increase efficiency. In contrast to systematic reviews that assess the effectiveness of distinct interventions, realist reviews focus on the mechanisms that link contexts with specific outcomes and identify which groups are the most and least likely to be affected by these outcomes and in what circumstances.32Wong G Greenhalgh T Westhorp G Buckingham J Pawson R RAMESES publication standards: realist syntheses.BMC Med. 2013; 11: 21Crossref PubMed Scopus (626) Google Scholar The logic of a realist review and evidence synthesis is based on the formation of causal statements between contexts, mechanisms, and outcomes (CMOs).32Wong G Greenhalgh T Westhorp G Buckingham J Pawson R RAMESES publication standards: realist syntheses.BMC Med. 2013; 11: 21Crossref PubMed Scopus (626) Google Scholar The literature review was registered with PROSPERO (CRD42020217871) and the protocol is available elsewhere.34Ford JA Gkiouleka A Kuhn I et al.Reducing health inequalities through general practice: protocol for a realist review (EQUALISE).BMJ Open. 2021; 11e052746Crossref Scopus (1) Google Scholar Building on our conceptual framework, we identified key theories about how general practice might increase or decrease health inequalities and integrated them into a broad theoretical explanation known as an initial programme theory.32Wong G Greenhalgh T Westhorp G Buckingham J Pawson R RAMESES publication standards: realist syntheses.BMC Med. 2013; 11: 21Crossref PubMed Scopus (626) Google Scholar We identified these theories through (1) an exploratory background literature search using informal methods (ie, snowballing and citation tracking);32Wong G Greenhalgh T Westhorp G Buckingham J Pawson R RAMESES publication standards: realist syntheses.BMC Med. 2013; 11: 21Crossref PubMed Scopus (626) Google Scholar (2) a panel discussion with content experts; and (3) iterative discussions within the project team. The initial programme theory covered a broad range of elements of context (ie, social, geographical, or other features affecting the implementation of interventions and care), mechanisms (ie, forces that cause things to happen), and outcomes (ie, the results of mechanisms). The initial programme theory served as an evaluative framework to guide our formal literature search and evidence collection,33Pawson R Greenhalgh T Harvey G Walshe K Realist review—a new method of systematic review designed for complex policy interventions.J Health Serv Res Policy. 2005; 10: 21-34Crossref PubMed Scopus (1666) Google Scholar with the areas that were then populated with evidence available in the appendix (p 2). Documents for the evidence synthesis were selected according to the extent to which they contained relevant data for the development and refinement of the programme theory.32Wong G Greenhalgh T Westhorp G Buckingham J Pawson R RAMESES publication standards: realist syntheses.BMC Med. 2013; 11: 21Crossref PubMed Scopus (626) Google Scholar AG classified studies in groups in this order: (1) studies which focused on inequalities in the UK were deemed of the highest relevance; (2) studies discussing interventions targeted at disadvantaged groups in the UK; (3) studies on interventions in the UK controlling for one or more PROGRESS-Plus (Cochrane Equity Methods Group) criteria35O'Neill J Tabish H Welch V et al.Applying an equity lens to interventions: using PROGRESS ensures consideration of socially stratifying factors to illuminate inequities in health.J Clin Epidemiol. 2014; 67: 56-64Summary Full Text Full Text PDF PubMed Scopus (509) Google Scholar in their analysis; (4) studies on inequalities outside the UK; (5) studies on interventions targeted at disadvantaged groups outside the UK; and (6) studies on interventions outside the UK controlling for one or more PROGRESS-Plus criteria in their analysis. Quality-assessment checklist criteria were not used as is conventionally the case in realist reviews;33Pawson R Greenhalgh T Harvey G Walshe K Realist review—a new method of systematic review designed for complex policy interventions.J Health Serv Res Policy. 2005; 10: 21-34Crossref PubMed Scopus (1666) Google Scholar rather, the rigour of the extracted data was considered during the coding and synthesis phase. Conforming with realist methodology, studies that contributed to the refinement of the programme theory were used in data synthesis even if they were of poor rigour.36Wong G Westhorp G Pawson R Greenhalgh T Realist synthesis: RAMESES training materials.https://www.ramesesproject.org/media/Realist_reviews_training_materials.pdfDate: July, 2013Date accessed: March 29, 2023Google Scholar To increase efficiency, article selection and data extraction were combined. Characteristics of all the included studies were extracted with an Excel sheet by AG and a research assistant. AG uploaded the included studies in QSR Nvivo (QSR International: Burlington, MA, USA) from most to least relevant and alphabetically by title, and coded relevant data with feedback from the research team. JF independently coded a random sample of approximately 5% of the articles to check for systematic errors. Articles were removed from the Nvivo sources list if they contained no relevant data. Data extraction stopped when no further data contributing to the programme theory were consistently identified (ie, thematic saturation).32Wong G Greenhalgh T Westhorp G Buckingham J Pawson R RAMESES publication standards: realist syntheses.BMC Med. 2013; 11: 21Crossref PubMed Scopus (626) Google Scholar Relevant text was searched manually in the full text of the included studies. Data were extracted by use of these questions: (1) does the text refer to any of the elements included in the initial programme theory? Or (2) does the text refer to the unequal effectiveness of care services or interventions? Codes were deductive (ie, created from the initial programme theory and identified with question 1), inductive (ie, created to categorise data reported in included studies and identified with question 2), or retroductive (ie, created on the basis of an interpretation of data to infer to what the hidden causal forces might be for outcomes and identified with both questions).32Wong G Greenhalgh T Westhorp G Buckingham J Pawson R RAMESES publication standards: realist syntheses.BMC Med. 2013; 11: 21Crossref PubMed Scopus (626) Google Scholar They were refined regularly throughout the data analysis and organised across 14 broader themes: access to care, communication, community engagement, competing priorities, cultural understanding, differences between general practices, interprofessional cooperation, patient education and behaviour change, patient enablement, patient perceived risk, resources distribution, the role of the general practitioner in intervention success, time constraints, and workforce.33Pawson R Greenhalgh T Harvey G Walshe K Realist review—a new method of systematic review designed for complex policy interventions.J Health Serv Res Policy. 2005; 10: 21-34Crossref PubMed Scopus (1666) Google Scholar We formed CMO configurations (CMOCs)32Wong G Greenhalgh T Westhorp G Buckingham J Pawson R RAMESES publication standards: realist syntheses.BMC Med. 2013; 11: 21Crossref PubMed Scopus (626) Google Scholar within and across themes. When necessary, we used questions about the relevance, rigour, and interpretation of data in line with previous work.37Wong G Brennan N Mattick K Pearson M Briscoe S Papoutsi C Interventions to improve antimicrobial prescribing of doctors in training: the IMPACT (IMProving Antimicrobial presCribing of doctors in Training) realist review.BMJ Open. 2015; 5e009059Crossref Scopus (28) Google Scholar Our synthesis aimed to elicit common patterns and generalisable messages across contexts and health conditions. Therefore, we focused on the underlying principles of care and interventions and CMOCs were abstracted to a high degree to reflect the principles of care and interventions that are likely to decrease or increase inequalities in general practice. We identified 7998 reviews of which 251 met the inclusion criteria. From the included reviews, we retrieved 6555 primary studies of which we included 325 (figure 1). The included primary studies covered a period from 1989 until 2021 and most were conducted in the USA (n=143) and the UK (n=102). 56 studies focused primarily on inequalities, 137 on an intervention or care targeted at specific disadvantaged groups, and 132 just controlled for at least one PROGRESS-Plus criterion (usually age or sex). More details about the characteristics of the included studies are available in the appendix (p 3). We coded 159 studies (appendix pp 55–80) before reaching thematic saturation. The evidence on interventions in general practice that address inequalities is disparate as it involves different kinds of interventions, settings, and populations. Moreover, although interventions seem to focus on single aspects of care (eg, invitations to screening programmes), their effectiveness is subject to other aspects (eg, availability of patient contact details). This finding stresses how inequalities are produced through context-specific, inter-related processes. Therefore, producing a list of distinct well defined interventions effective in reducing inequalities in health or care would have been impractical, given the length of such a list, and of little use given that interventions are context-specific. However, there is transferrable evidence about common qualities that inform successful interventions, which was the subject of our focus. We produced 21 CMOCs, which we organised across the four domains of power organisation in line with our conceptual framework. This way, we captured how inequalities are produced across different aspects of care while producing transferrable conclusions, resulting in an action framework for equitable general practice (figure 2). The framework identifies key areas of action for the reduction of health and care inequalities in general practice across the structural, cultural, disciplinary, and interpersonal domains and suggests five principles that should inform relevant action. We discuss the identified action areas with some examples of the CMOCs included in each domain and the meaning of each suggested principle in the context of the reviewed evidence. An elaborated account of the evidence synthesis and CMOCs production from the reviewed evidence is available in the appendix (pp 4–28). In the structural domain, key areas include funding and workforce distributions, which are often unable to account for differences in needs within and between practices (figure 2; appendix p 7).38Fullwood C Doran T Reeves D The effect of financial incentives on inequalities in the quality of primary care.J Epidemiol Community Health. 2008; 62: A21Google Scholar, 39Laverty AA Bottle A Majeed A Millett C Blood pressure monitoring and control by cardiovascular disease status in UK primary care: 10 year retrospective cohort study 1998–2007.J Public Health. 2011; 33: 302-309Crossref Scopus (0) Google Scholar, 40McLean G Sutton M Guthrie B Deprivation and quality of primary care services: evidence for persistence of the inverse care law from the UK Quality and Outcomes Framework.J Epidemiol Community Health. 2006; 60: 917-922Crossref PubMed Scopus (0) Google Scholar, 41Calvert M Shankar A McManus RJ Lester H Freemantle N Effect of the quality and outcomes framework on diabetes care in the United Kingdom: retrospective cohort study.BMJ. 2009; 338b1870Crossref PubMed Scopus (126) Google Scholar, 42Dalton AR Alshamsan R Majeed A Millett C Exclusion of patients from quality measurement of diabetes care in the UK pay-for-performance programme.Diabet Med. 2011; 28: 525-531Crossref PubMed Scopus (25) Google Scholar, 43McGovern MP Williams DJ Hannaford PC et al.Introduction of a new incentive and target-based contract for family physicians in the UK: good for older patients

Abstract: BackgroundDrug-related death (DRD) rate in Scotland, UK, has increased rapidly to one of the highest in the world. Our aim was to examine the extent to which opioid-agonist therapy (OAT) in Scotland is protective against drug-related mortality and how this effect has varied over time.MethodsWe included individuals in Scotland with opioid use disorder who received at least one OAT prescription between Jan 1, 2011, and Dec 31, 2020. We calculated drug-related mortality rates and used Quasi-Poisson regression models to estimate trends over time and by OAT exposure, adjusting for potential confounding.FindingsIn a cohort of 46 453 individuals prescribed OAT with a total of 304 000 person-years of follow-up, DRD rates more than trebled from 6·36 per 1000 person-years (95% CI 5·73–7·01) in 2011–12 to 21·45 (20·31–22·63) in 2019–20. DRD rates were almost three and a half times higher (hazard ratio 3·37; 95% CI 1·74–6·53) for those off OAT compared with those on OAT after adjustment for confounders. However, confounder adjusted DRD risk increased over time for both people off and on OAT.InterpretationDrug-related mortality rates among people with opioid use disorders in Scotland increased between 2011 and 2020. OAT remains protective but is insufficient on its own to slow the increase in DRD risk for people who are opioid dependent in Scotland.FundingScottish Government Drug Deaths Taskforce, Public Health Scotland, and National Institute for Health and Care Research. Drug-related death (DRD) rate in Scotland, UK, has increased rapidly to one of the highest in the world. Our aim was to examine the extent to which opioid-agonist therapy (OAT) in Scotland is protective against drug-related mortality and how this effect has varied over time. We included individuals in Scotland with opioid use disorder who received at least one OAT prescription between Jan 1, 2011, and Dec 31, 2020. We calculated drug-related mortality rates and used Quasi-Poisson regression models to estimate trends over time and by OAT exposure, adjusting for potential confounding. In a cohort of 46 453 individuals prescribed OAT with a total of 304 000 person-years of follow-up, DRD rates more than trebled from 6·36 per 1000 person-years (95% CI 5·73–7·01) in 2011–12 to 21·45 (20·31–22·63) in 2019–20. DRD rates were almost three and a half times higher (hazard ratio 3·37; 95% CI 1·74–6·53) for those off OAT compared with those on OAT after adjustment for confounders. However, confounder adjusted DRD risk increased over time for both people off and on OAT. Drug-related mortality rates among people with opioid use disorders in Scotland increased between 2011 and 2020. OAT remains protective but is insufficient on its own to slow the increase in DRD risk for people who are opioid dependent in Scotland.

Abstract: BackgroundAmbient air pollution is a major risk to health and wellbeing in European cities. We aimed to estimate spatial and sector-specific contributions of emissions to ambient air pollution and evaluate the effects of source-specific reductions in pollutants on mortality in European cities to support targeted source-specific actions to address air pollution and promote population health.MethodsWe conducted a health impact assessment of data from 2015 for 857 European cities to estimate source contributions to annual PM2·5 and NO2 concentrations using the Screening for High Emission Reduction Potentials for Air quality tool. We evaluated contributions from transport, industry, energy, residential, agriculture, shipping, and aviation, other, natural, and external sources. For each city and sector, three spatial levels were considered: contributions from the same city, the rest of the country, and transboundary. Mortality effects were estimated for adult populations (ie, ≥20 years) following standard comparative risk assessment methods to calculate the annual mortality preventable on spatial and sector-specific reductions in PM2·5 and NO2.FindingsWe observed strong variability in spatial and sectoral contributions among European cities. For PM2·5, the main contributors to mortality were the residential (mean contribution of 22·7% [SD 10·2]) and agricultural (18·0% [7·7]) sectors, followed by industry (13·8% [6·0]), transport (13·5% [5·8]), energy (10·0% [6·4]), and shipping (5·5% [5·7]). For NO2, the main contributor to mortality was transport (48·5% [SD 15·2]), with additional contributions from industry (15·0% [10·8]), energy (14·7% [12·9]), residential (10·3% [5·0]), and shipping (9·7% [12·7]). The mean city contribution to its own air pollution mortality was 13·5% (SD 9·9) for PM2·5 and 34·4% (19·6) for NO2, and contribution increased among cities of largest area (22·3% [12·2] for PM2·5 and 52·2% [19·4] for NO2) and among European capitals (29·9% [12·5] for PM2·5 and 62·7% [14·7] for NO2).InterpretationWe estimated source-specific air pollution health effects at the city level. Our results show strong variability, emphasising the need for local policies and coordinated actions that consider city-level specificities in source contributions.FundingSpanish Ministry of Science and Innovation, State Research Agency, Generalitat de Catalunya, Centro de Investigación Biomédica en red Epidemiología y Salud Pública, and Urban Burden of Disease Estimation for Policy Making 2023–2026 Horizon Europe project. Ambient air pollution is a major risk to health and wellbeing in European cities. We aimed to estimate spatial and sector-specific contributions of emissions to ambient air pollution and evaluate the effects of source-specific reductions in pollutants on mortality in European cities to support targeted source-specific actions to address air pollution and promote population health. We conducted a health impact assessment of data from 2015 for 857 European cities to estimate source contributions to annual PM2·5 and NO2 concentrations using the Screening for High Emission Reduction Potentials for Air quality tool. We evaluated contributions from transport, industry, energy, residential, agriculture, shipping, and aviation, other, natural, and external sources. For each city and sector, three spatial levels were considered: contributions from the same city, the rest of the country, and transboundary. Mortality effects were estimated for adult populations (ie, ≥20 years) following standard comparative risk assessment methods to calculate the annual mortality preventable on spatial and sector-specific reductions in PM2·5 and NO2. We observed strong variability in spatial and sectoral contributions among European cities. For PM2·5, the main contributors to mortality were the residential (mean contribution of 22·7% [SD 10·2]) and agricultural (18·0% [7·7]) sectors, followed by industry (13·8% [6·0]), transport (13·5% [5·8]), energy (10·0% [6·4]), and shipping (5·5% [5·7]). For NO2, the main contributor to mortality was transport (48·5% [SD 15·2]), with additional contributions from industry (15·0% [10·8]), energy (14·7% [12·9]), residential (10·3% [5·0]), and shipping (9·7% [12·7]). The mean city contribution to its own air pollution mortality was 13·5% (SD 9·9) for PM2·5 and 34·4% (19·6) for NO2, and contribution increased among cities of largest area (22·3% [12·2] for PM2·5 and 52·2% [19·4] for NO2) and among European capitals (29·9% [12·5] for PM2·5 and 62·7% [14·7] for NO2). We estimated source-specific air pollution health effects at the city level. Our results show strong variability, emphasising the need for local policies and coordinated actions that consider city-level specificities in source contributions.

Abstract: Low emission zones (LEZs) and congestion charging zones (CCZs) have been implemented in several cities globally. We systematically reviewed the evidence on the effects of these air pollution and congestion reduction schemes on a range of physical health outcomes. We searched MEDLINE, Embase, Web of Science, IDEAS, Greenfile, and Transport Research International Documentation databases from database inception to Jan 4, 2023. We included studies that evaluated the effect of implementation of a LEZ or CCZ on air pollution-related health outcomes (cardiovascular and respiratory diseases, birth outcomes, dementia, lung cancer, diabetes, and all-cause) or road traffic injuries (RTIs) using longitudinal study designs and empirical health data. Two authors independently assessed papers for inclusion. Results were narratively synthesised and visualised using harvest plots. Risk of bias was assessed using the Graphic Appraisal Tool for Epidemiological studies. The protocol was registered with PROSPERO (CRD42022311453). Of 2279 studies screened, 16 were included, of which eight assessed LEZs and eight assessed CCZs. Several LEZ studies identified positive effects on air pollution-related outcomes, with reductions in some cardiovascular disease subcategories found in five of six studies investigating this outcome, although results for other health outcomes were less consistent. Six of seven studies on the London CCZ reported reductions in total or car RTIs, although one study reported an increase in cyclist and motorcyclist injuries and one reported an increase in serious or fatal injuries. Current evidence suggests LEZs can reduce air pollution-related health outcomes, with the most consistent effect on cardiovascular disease. Evidence on CCZs is mainly limited to London but suggests that they reduce overall RTIs. Ongoing evaluation of these interventions is necessary to understand longer term health effects.

Abstract: Although socioeconomic inequality in cardiovascular health has long been a public health focus, the differences in cardiovascular-disease burden and mortality between people with different socioeconomic statuses has yet to be adequately addressed. We aimed to assess the effects of socioeconomic status, measured via three socioeconomic-status indicators (ie, education, occupation, and household wealth and a composite socioeconomic-status disparity index, on mortality and cardiovascular-disease burden (ie, incidence, mortality, and admission to hospital) in China.For this analysis, we used data from the Prospective Urban Rural Epidemiology (PURE)-China cohort study, which enrolled adults aged 35-70 years from 115 urban and rural areas in 12 provinces in China between Jan 1, 2005, and Dec 31, 2009. Final follow-up was on Aug 30, 2021. Indicators of socioeconomic status were education, occupation, and household wealth; these individual indicators were also used to create an integrated socioeconomic-status index via latent class analysis. Standard questionnaires administered by trained researchers were used to obtain baseline data and were supplemeted by physical measurements. The primary outcomes were all-cause mortality, cardiovascular-disease mortality, non-cardiovascular-disease mortality, major cardiovascular disease, and cardiovascular-disease admission to hospital. Hazard ratios (HRs) and average marginal effects were used to assess the association between the primary outcomes and socioeconomic status.Of 47 931 participants enrolled in the PURE-China study, 47 278 (98·6%) had complete information on sex and follow-up. After excluding 1189 (2·5%) participants with missing data on education, household wealth, and occupation at baseline, 46 089 participants were included in this analysis. Median follow-up was 11·9 years (IQR 9·5-12·6); 26 860 (58·3%) of 46 089 participants were female and 19 229 (41·7%) were male. Having no or primary education, unskilled occupation, or being in the lowest third of household wealth was associated with a higher risk of all-cause mortality, cardiovascular-disease mortality, non-cardiovascular-disease mortality, major cardiovascular disease, and cardiovascular-disease admission to hospital compared with having higher education, a professional or managerial occupation, or more household wealth. After adjustment for confounders, people categorised as having low integrated socioeconomic status based on the index had a higher risk of all-cause mortality (HR 1·65 [95% CI 1·42-1·92]), cardiovascular-disease mortality (2·19 [1·68-2·85]), non-cardiovascular disease mortality (1·43 [1·18-1·72]), major cardiovascular disease (1·43 [1·27-1·61]) and cardiovascular-disease admission to hospital (1·14 [1·01-1·28]) compared with people categorised as having high integrated socioeconomic status.Socioeconomic-status inequalities in mortality and cardiovascular-disease outcomes exist in China. Targeted policies of equal health-care resource allocation should be promoted to equitably benefit people with fewer years of education and less household wealth.Funding sources are listed at the end of the Article.

Abstract: Background To plan social and health services, future life expectancy projections are needed. The aim of this study was to forecast the future life expectancy for mainland China and its provinces. Methods Following the same approach as the Global Burden of Disease Study, we used the largest compiled epidemiological and demographic datasets to estimate age-specific mortality and evaluate population data from 1990 to 2019. A total of 21 life expectancy forecasting models were combined by a probabilistic Bayesian model to forecast the life expectancy for mainland China and its provinces in 2035. Findings The projected life expectancy at birth in mainland China in 2035 is 81·3 years (95% credible interval 79·2–85·0), and there is a high probability that the national goals of improving life expectancy will be achieved (79 years in 2030, and over 80 years in 2035). At the provincial level, women in Beijing have the highest projected life expectancy in 2035 with an 81% probability of reaching 90 years, followed by Guangdong, Zhejiang, and Shanghai, which all have more than a 50% probability of surpassing 90 years. Men in Shanghai are projected to have the highest life expectancy at birth in 2035, with a 77% probability of life expectancy being over 83 years, the highest provincial life expectancy in mainland China in 2019. The projected gains in life expectancy are mainly derived from older individuals (aged ≥65 years), except those in Xinjiang, Tibet, and Qinghai (for men), in which the main contributions come from younger (0–29 years) or middle-aged (30–64 years) individuals. Interpretation Life expectancy in mainland China and its provinces has a high probability of continuing to increase through to 2035. Adequate policy planning of social and health services will be needed. Funding China National Natural Science Foundation and Social Science Fund of Jiangsu Province.

Abstract: Most cervical cancer in the USA occurs in under-screened women. The My Body, My Test-3 (MBMT-3) trial sought to assess the efficacy of mailed human papillomavirus (HPV) self-collection kits with appointment-scheduling assistance to increase uptake of cervical cancer screening among under-screened women from low-income backgrounds compared with scheduling assistance alone.MBMT-3 is a phase 3, open-label, two-arm, randomised controlled trial. Participants were recruited from 22 counties in North Carolina state, USA, and we partnered with 21 clinics across these counties. Participants were eligible for inclusion if they were aged 25-64 years, had an intact cervix, were uninsured or enrolled in Medicaid or Medicare, had an income of 250% or less of the US Federal Poverty Level, were living within the catchment area of a trial-associated clinic, and were overdue for screening (ie, Papanicolaou test ≥4 years ago or high-risk HPV test ≥6 years ago). Participants were randomly assigned (2:1) to receive a mailed HPV self-collection kit and assistance for scheduling a free screening appointment (intervention group) or to receive scheduling assistance alone (control group). Randomisation was conducted by county using permuted blocks of nine patients and assignment to group was not masked. Participants in the intervention group were mailed HPV self-collection kits to collect a cervical-vaginal sample and return it by mail for testing. Samples were tested with the Aptima HPV assay (Hologic, San Diego, CA, USA), and participants were informed of high-risk HPV results by telephone call. Trial staff made up to three telephone call attempts to provide scheduling assistance for in-clinic screening for all participants. The primary outcome was cervical cancer screening uptake (ie, attending an in-clinic screening appointment or testing negative for high-risk HPV with a returned self-collected sample) within 6 months of enrolment in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, NCT02651883, and has been completed.Recruitment occurred between April 11, 2016, and Dec 16, 2019. 4256 women contacted the trial to participate, of whom 899 (21%) were eligible for inclusion and 697 (78%) returned consent forms. Of those who consented, 461 (66%) women were randomly assigned to the intervention group and 236 (34%) women were randomly assigned to the control group. We excluded 32 ineligible women post-randomisation, leaving 665 for primary analysis. Screening uptake was higher in the intervention group (317 [72%] of 438) than control group (85 [37%] of 227; risk ratio 1·93, 95% CI 1·62-2·31). Among intervention participants, 341 (78%) of 438 returned a self-collection kit. Three participants reported hurt or injury when using the self-collection kit; no participants withdrew due to adverse effects.Among under-screened women from low-income backgrounds, mailed HPV self-collection kits with scheduling assistance led to greater uptake of cervical cancer screening than scheduling assistance alone. At-home HPV self-collection testing has the potential to increase screening uptake among under-screened women.National Cancer Institute.

Abstract: This report analyses the underlying causes of China's achievements and gaps in universal health coverage over the past 2 decades and proposes policy recommendations for advancing universal health coverage by 2030. Although strong political commitment and targeted financial investment have produced positive outcomes in reproductive, maternal, newborn, and child health and infectious diseases, a fragmented and hospital-centric delivery system, rising health-care costs, shallow benefit coverage of health insurance schemes, and little integration of health in all policies have restricted China's ability to effectively prevent and control chronic disease and provide adequate financial risk protection, especially for lower-income households. Here, we used a health system conceptual framework and we propose a set of feasible policy recommendations that draw from international experiences and first-hand knowledge of China's unique institutional landscape. Our six recommendations are: instituting a primary care-focused integrated delivery system that restructures provider incentives and accountability mechanisms to prioritise prevention; leveraging digital tools to support health behaviour change; modernising information campaigns; improving financial protection through insurance reforms; promoting a health in all policy; and developing a domestic monitoring framework with refined tracer indicators that reflects China's disease burden.

Abstract: BackgroundWorkplace offensive behaviours, such as violence and bullying, have been linked to psychological symptoms, but their potential impact on suicide risk remains unclear. We aimed to assess the association of workplace violence and bullying with the risk of death by suicide and suicide attempt in multiple cohort studies.MethodsIn this multicohort study, we used individual-participant data from three prospective studies: the Finnish Public Sector study, the Swedish Work Environment Survey, and the Work Environment and Health in Denmark study. Workplace violence and bullying were self-reported at baseline. Participants were followed up for suicide attempt and death using linkage to national health records. We additionally searched the literature for published prospective studies and pooled our effect estimates with those from published studies.FindingsDuring 1 803 496 person-years at risk, we recorded 1103 suicide attempts or deaths in participants with data on workplace violence (n=205 048); the corresponding numbers for participants with data on workplace bullying (n=191 783) were 1144 suicide attempts or deaths in 1 960 796 person-years, which included data from one identified published study. Workplace violence was associated with an increased risk of suicide after basic adjustment for age, sex, educational level, and family situation (hazard ratio 1·34 [95% CI 1·15–1·56]) and full adjustment (additional adjustment for job demands, job control, and baseline health problems, 1·25 [1·08–1·47]). Where data on frequency were available, a stronger association was observed among people with frequent exposure to violence (1·75 [1·27–2·42]) than occasional violence (1·27 [1·04–1·56]). Workplace bullying was also associated with an increased suicide risk (1·32 [1·09–1·59]), but the association was attenuated after adjustment for baseline mental health problems (1·16 [0·96–1·41]).InterpretationObservational data from three Nordic countries suggest that workplace violence is associated with an increased suicide risk, highlighting the importance of effective prevention of violent behaviours at workplaces.FundingSwedish Research Council for Health, Working Life and Welfare, Academy of Finland, Finnish Work Environment Fund, and Danish Working Environment Research Fund. Workplace offensive behaviours, such as violence and bullying, have been linked to psychological symptoms, but their potential impact on suicide risk remains unclear. We aimed to assess the association of workplace violence and bullying with the risk of death by suicide and suicide attempt in multiple cohort studies. In this multicohort study, we used individual-participant data from three prospective studies: the Finnish Public Sector study, the Swedish Work Environment Survey, and the Work Environment and Health in Denmark study. Workplace violence and bullying were self-reported at baseline. Participants were followed up for suicide attempt and death using linkage to national health records. We additionally searched the literature for published prospective studies and pooled our effect estimates with those from published studies. During 1 803 496 person-years at risk, we recorded 1103 suicide attempts or deaths in participants with data on workplace violence (n=205 048); the corresponding numbers for participants with data on workplace bullying (n=191 783) were 1144 suicide attempts or deaths in 1 960 796 person-years, which included data from one identified published study. Workplace violence was associated with an increased risk of suicide after basic adjustment for age, sex, educational level, and family situation (hazard ratio 1·34 [95% CI 1·15–1·56]) and full adjustment (additional adjustment for job demands, job control, and baseline health problems, 1·25 [1·08–1·47]). Where data on frequency were available, a stronger association was observed among people with frequent exposure to violence (1·75 [1·27–2·42]) than occasional violence (1·27 [1·04–1·56]). Workplace bullying was also associated with an increased suicide risk (1·32 [1·09–1·59]), but the association was attenuated after adjustment for baseline mental health problems (1·16 [0·96–1·41]). Observational data from three Nordic countries suggest that workplace violence is associated with an increased suicide risk, highlighting the importance of effective prevention of violent behaviours at workplaces.