Health shocks and their long-lasting impact on health behaviors: Evidence from the 2009 H1N1 pandemic in Mexico

Review of research advances in microbial sterilization technologies and applications in the built environment

As globalization accelerates, microbial contamination in the built environment poses a major public health challenge. Especially since Corona Virus Disease 2019 (COVID-19), microbial sterilization technology has become a crucial research area for indoor air pollution control in order to create a hygienic and safe built environment. Based on this, the study reviews sterilization technologies in the built environment, focusing on the principles, efficiency and applicability, revealing advantages and limitations, and summarizing current research advances. Despite the efficacy of single sterilization technologies in specific environments, the corresponding side effects still exist. Thus, this review highlights the efficiency of hybrid sterilization technologies, providing an in-depth understanding of the practical application in the built environment. Also, it presents an outlook on the future direction of sterilization technology, including the development of new methods that are more efficient, energy-saving, and targeted to better address microbial contamination in the complex and changing built environment. Overall, this study provides a clear guide for selecting technologies to handle microbial contamination in different building environments in the future, as well as a scientific basis for developing more effective air quality control strategies.

Does timing matter? The role of health information shocks in measuring willingness to pay

OBJECTIVES

The optimal point in time to measure willingness-to-pay (WTP) remains unclear. We investigated the role of health information shocks (HIS) in individuals' WTP, analyzing the extent to which news of SARS-CoV-2 infections among people they know/themselves altered WTP for booster vaccinations.

METHODS

We elicited WTP in eight European countries using the European Covid Survey. First, we presented participants with a hypothetical setting recommending a booster vaccination that had to be paid out-of-pocket. To measure WTP, we elicited a lower and upper WTP limit, and a WTP value contingent on both of these. To measure HIS, we asked about the duration since participants received news of COVID-19 cases among people they know (including themselves), as well as the degree of personal connection to these cases and their severity. We used a two-part model to estimate the association between HIS and individuals' WTP.

RESULTS

Among the 5809 observations, 76.8% stated a WTP for a booster vaccination greater than €0. At least one HIS was reported by 61.9% of participants. The occurrence of a HIS was associated with an increase in WTP of €14.54 (logistic: P <.0001, gamma: P =.1493) compared to no HIS. The WTP was higher when the HIS occurred in the four weeks before the survey. Controlling for socio-demographic and COVID-19 covariates decreased significance and effect sizes.

CONCLUSION

Our findings suggest that a recent HIS is associated with a higher probability of having a positive WTP. Timing, in relation to some relevant event, therefore may matter when measuring WTP for health interventions. If so, finding the optimal point in time to measure WTP is difficult and may depend on the policy question under consideration.

Causal Relationship Between Physical Activity and Body Weight: A Maximum Likelihood Treatment Effect Model Approach Using Australian Longitudinal Data

BACKGROUND

More than two-thirds of Australians are overweight. Existing research based on non-experimental data has primarily established associations, rather than causal inferences, between physical activity (PA) and body mass index (BMI). PA and BMI likely affect each other, a reciprocal interplay most studies overlook. We investigate the causal relationship between PA and BMI using a quasi-experimental approach to overcome reverse causality bias.

METHOD

A maximum likelihood treatment effect model, a quasi-experimental method, was employed. Data was from an observational longitudinal dataset of 130,397 observations with 19,677 unique individuals aged 15-64 (52% are females) from the Household, Income, and Labour Dynamics in Australia survey 2006-2019. We first tested for the reverse relationships (whereby overweight limits PA) before estimating the effect of PA on BMI.

RESULTS

The first-stage modelling results showed that overweight and obese adults are less likely to engage in PA, as are those resource constrained (time or socioeconomically). In the second modelling stage, there was a clear and significant effect of PA on BMI. Being physically active more than three times a week led to a 2.55-point reduction in BMI (p < 0.001). For women, this effect was more pronounced, with a 2.92-point reduction (p < 0.001).

CONCLUSION

This study leverages existing longitudinal data to provide causal estimates of PA on BMI-finding that PA reduces BMI, particularly for women. As many individuals face resource constraints, campaigns to promote behavioural change need to be nuanced and shift some of the responsibility for physically activity from individuals to policy and organizational reforms.

A study on the impact of health shocks on subjective wellbeing of middle-aged people and older adults-Evidence from China

Introduction

The health issues that afflict middle-aged people and older individuals are a significant factor that affects their quality of life. It is crucial to investigate the impact of health shocks on the subjective wellbeing of this demographic and the mechanisms that underlie this impact to promote healthy aging.

Methods

This study utilized data from the China Family Panel Study in 2018 and 2020 to analyze the effects of HSs and their categories on the subjective wellbeing of middle-aged people and older individuals using the propensity score matching difference-in-differences method. Additionally, the study explored the mediating role of social participation.

Results

The findings indicate that health shocks, both chronic and acute, diminish the subjective wellbeing of middle-aged people and older adults. Furthermore, these shocks have a more significant negative effect on the subjective wellbeing of individuals aged 60 and above, women in the middle-aged and older demographic, individuals in rural areas who belong to the middle-aged and older age groups, and individuals possessing activities of daily living. The mechanism analysis revealed that health shocks, both chronic and acute, reduce the subjective wellbeing of middle-aged people and older individuals by disrupting partnerships.

Discussion

Lowering the possibility of health shocks, the government should build a strong health management system and improve the health insurance system to enable timely treatment for persons suffering from health shocks. Individuals and families should live healthy lives and engage in social activities to avoid health shocks and improve subjective wellbeing.

Effects of private health insurance on healthcare services during the MERS Pandemic: Evidence from Korea

This study investigates how private health insurance impacted healthcare services during the MERS pandemic in Korea. Using the Korea Health Panel Study (KHPS), this study examines the difference in healthcare utilization between insured and uninsured individuals during the pandemic. If insured individuals use fewer healthcare services than the uninsured during the MERS pandemic, it could be evidence of moral hazard. During the MERS outbreak, the probability of outpatient medical services utilization was lower by 19 % than during non-pandemic periods. All individuals decreased the number of outpatient visits by 7 %. Insured individuals reduced outpatient visits more than the uninsured in response to the MERS pandemic. The increased outpatient utilization by private health insurance could be attributed to both moral hazard and adverse selection. However, given that people with poor health cannot enroll in private health insurance due to the insurance company's screening process, moral hazard leads to increase healthcare utilization rather than adverse selection.

Mothers as insurance: Family spillovers in WIC

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a widely used program. Previous research shows that WIC improves birth outcomes, but evidence about impacts on older children and their families is limited. We use a regression discontinuity leveraging a loss of benefits at age five when children become ineligible for WIC and examine nutritional and laboratory outcomes for adults and children. We find little impact on children who aged out of the program. But caloric intake falls and food insecurity increases among adult women, suggesting that mothers protect children by consuming less themselves. We find no effect on others in the household.

Earthquake exposure during adolescence and later-life depressive symptoms: A national cross-sectional survey

Background

This study aimed to examine the association between exposure to the 1976 Great Tangshan Earthquake (GTE) in adolescence and later-life depressive symptoms and to investigate the potential mechanisms underlying this association.

Methods

Data were from the 2015 China Health and Retirement Longitudinal Study (CHARLS). The 10-item short form of the Center for Epidemiologic Studies Depression scale (CESD-10) was chosen to measure depressive symptoms. We used the difference-in-difference (DID) method, binary logistic regression models, and multilevel logistic regression models to explore the association of earthquake exposure during adolescence with later-life depressive symptoms. Additionally, multilevel mediation analysis with structural equation modeling (MMSEM) was conducted to investigate potential mechanisms.

Results

We identified that adolescent exposure to earthquakes was related to a lower risk of depressive symptoms in later life (OR = 0.90, P = 0.019; OR = 0.48, P = 0.031; OR = 0.47, P = 0.034, respectively). However, this significant association was observed only in females (OR = 0.83, P = 0.028; OR = 0.46, P = 0.053; OR = 0.42, P = 0.037, respectively). Moreover, social activity participation played a mediating role in the association between exposure to earthquakes in adolescence and later-life depressive symptoms.

Conclusions

We observed a lower risk of depressive symptoms in later life in survivors of earthquake exposure during adolescence. Further, we found the mediating role of social participation in the association between earthquake exposure in adolescence and later-life depressive symptoms, which gives support for the posttraumatic growth (PTG) theory. Our findings imply that, in order to lower the risk of depression in later life following exposure to a natural disaster in adolescence, it is necessary to take into account the buffering effect of social participation.

Does paid sick leave encourage staying at home? Evidence from the United States during a pandemic

We study the impact of a temporary U.S. paid sick leave mandate that became effective April 1st, 2020 on self-quarantining, proxied by physical mobility behaviors gleaned from cellular devices. We study this policy using generalized difference-in-differences methods, leveraging pre-policy county-level heterogeneity in the share of workers likely eligible for paid sick leave benefits. We find that the policy leads to increased self-quarantining as proxied by staying home. We also find that COVID-19 confirmed cases decline post-policy.

The social scar of the pandemic: Impacts of COVID-19 exposure on interpersonal trust

This paper employs a difference-in-differences strategy to examine the causal effect of exposure to the COVID-19 pandemic on interpersonal trust amidst zero-COVID policies in China. Using a nationally representative panel survey, we find that COVID-19 exposure leads to a decrease in the levels of generalized trust. We also show that the change in interpersonal trust varies across domains. Specifically, COVID-19 exposure significantly decreases trust in parents, neighbors, and local government officials, but has small and insignificant effects on trust in doctors, strangers, and Americans. Empirical tests suggest that changes in income and physical health status are not likely to be potential channels. We provide some evidence for the mechanism of deteriorated mental health status and pessimistic expectations.

Changes in water treatment, hygiene practices, household floors, and child health in times of Covid-19: A longitudinal cross-sectional survey in Surkhet District, Nepal

INTRODUCTION

Consistent and effective practice of water treatment, sanitation, and hygiene (WASH) behaviour is an indispensable requisite for realizing health improvements among children living in low-income areas with challenging hygienic conditions. Sustainably achieving such a behaviour change is challenging but more likely to be realized during epidemics, when health threats are high and the dissemination of information on preventative measures is intense. Our study conducted cross-sectional surveys in Surkhet District Nepal, before and during the Covid-19 pandemic to assess the impact of water safety interventions and hygiene training implemented before and during the pandemic on WASH conditions and practices and to assess the association of these changes with child health.

METHODS

Information on WASH infrastructure, WASH behaviour, nutrition, and child health, including on parasitic infections, was obtained before and during the Covid-19 pandemic in spring 2018 and spring 2021, from 589 children aged between 6 months and 10 years and their caregivers. Data was collected through quantitative, structured face-to-face interviews, observations, health examinations of children including anthropometric measurements, analysis of children's stool, and water quality analysis. The association of changes in WASH factors with changes in child health was analysed using multivariate generalized estimating equations for repeated measures.

RESULTS

Water safety management was significantly improved by the introduction of chlorination to piped water supply systems, which served 40% of households. In addition, the percentage of households using a ceramic water filter increased from 12.2% to 34.8%. Large and significant changes were observed in handwashing behaviour (frequency, use of soap and washing at critical times) and infrastructure: 35% of households constructed a new handwashing station. Kitchen and household hygiene also improved. An additional 22% of households improved the cleanliness of the toilet. The number of houses with a cemented floor increased by 20%. WASH changes were significantly associated with improved child health: the chlorination of piped water supply reduced odds ratios for diarrhoea (OR = 0.36, 95% CI = 0.15-0.88, p = 0.025), respiratory difficulties (OR = 0.39, 95% CI = 0.16-0.92, p = 0.033), fever (OR = 0.42, 95% CI = 0.26-0.71, p = 0.001) and cough (OR = 0.58, 95% CI = 0.36-0.93, p = 0.024), and. The frequency of handwashing with soap was associated with significantly reduced odds ratios for infections with Giardia lamblia (OR = 0.68, 95% CI = 0.50-0.91, p = 0.011), stunting and wasting (OR = 0.75, 95% CI = 0.66-0.92, p = 0.003) and fever (OR = 0.85, 95% CI = 0.75-0.96, p = 0.008),. The presence of a handwashing station at baseline was associated with significantly reduced odds ratios for respiratory difficulties (OR = 0.45, 95% CI = 0.26-0.78, p = 0.004). The construction of a handwashing station between baseline and endline was significantly associated with reduced odds ratios for pale conjunctiva (OR = 0.32, 95% CI = 0.17-0.60, p < 0.001), which is a clinical sign of iron deficiency and anaemia, respiratory difficulties (OR = 0.39, 95% CI = 0.17-0.89, p = 0.026) and cough (OR = 0.44, 95% CI = 0.26-0.76, p = 0.003). Using a clean container for the transport of drinking water was significantly associated with reduced odds ratios for infections with Giardia lamblia (OR = 0.39, 95% CI = 0.16-0.93, p = 0.033) and diarrhoea (OR = 0.48, 95% CI = 0.24-0.96, p = 0.038). Similarly, a cemented floor in the household was significantly associated with reduced odd ratios for diarrhoea (OR = 0.38, 95% CI = 0.16-0.87, p = 0.022) and infections with Giardia lamblia (OR = 0.44, 95% CI = 0.19-1.02, p = 0.056).

CONCLUSION

WASH training and the promotion of preventative measures during the Covid-19 pandemic supported improved water safety management and hygiene behaviour, which resulted in a reduction in infectious diseases among children in the study area.

Unintended health benefits of adopting preventive behaviors during a virus outbreak

This study investigates whether changes in risk perception play a critical role in improving of preventive behaviors and health outcomes by examining the 2009 H1N1 influenza (or swine flu) pandemic in Korea. We employ a difference-in-differences estimation strategy by comparing the differential effects of the H1N1 outbreak on the confirmed cases of diseases which can be prevented by preventive behaviors (e.g., intestinal infections) and the cases of diseases which cannot (e.g., injuries). Using unique administrative data from South Korea's National Health Insurance Service (NHIS), we find that the exogenous increase in health risk reduced the incidence of intestinal infections compared to the injuries during the H1N1 influenza outbreak. The reduction was the most substantial among children under five years of age, with a 25.4% decline in cases of intestinal infections relative to injuries. Our findings are robust across various alternative specifications. We provide suggestive evidence that active adoption of preventive behaviors is one of the channels underlying the unexpected decrease in diarrhea cases. The effects, however, faded away shortly after the end of the pandemic and did not last in the long run.

The Impact of the COVID-19 Pandemic on the Mental Health of Urban Residents-Evidence from China

Based on a nationwide micro-survey in China from 2018 to 2021, this paper empirically estimates the causal impact of the COVID-19 pandemic on the mental health of Chinese residents, by exploiting the distribution of the outflow population from Wuhan as an instrumental variable (IV). Our findings suggest that for every 10% increase in the cumulative confirmed cases, the number of mentally unhealthy days reported by urban residents in the past 30 days will increase by 2.19, an increase of 46.90% compared with the mean value. The impact is more significant among females, people aged 30 or above, and private-sector employees. Further evidence highlights the negative impact of the COVID-19 pandemic on residents' expectations of future income and confidence in macroeconomic development, both of which we interpret as mechanisms related to economic concerns. In addition, application of the multi-period difference-in-differences (DID) strategy revealed that the negative impact still exists two years post-pandemic, but it has been dramatically alleviated since the initial stage.

Public health shocks, learning and diet improvement

Many governments aim to mitigate health risks by attacking nutritional failures. In this article, we exploit a unique natural experiment, the COVID-19 pandemic as an exogenous public health shock, to estimate the learning effects of intensive health information campaigns on nutrient intake during the pandemic. Using data from nearly-one million food purchases in China, our empirical findings strongly support the learning effect in explaining improvements in nutrient intake in the post-COVID-19 period. We conclude that when public health shocks occur, policy makers can boost relevant learning mechanisms by promoting information and education to improve individuals' awareness of preventive health behaviors of a more permanent nature, which can lead to health improvements in a society.

Using Pandemic Behavior to Test the External Validity of Laboratory Measurements of Risk Aversion and Guilt

We test whether laboratory measures of individual preferences for risk and guilt relate to risk-connected behaviors in a pandemic, such as socializing, dining in at restaurants, and hand washing. We utilize a survey administrated to a nationally representative subject pool in the United States in April, 2020 - the month following the declaration of a national state of emergency in response to the global outbreak of COVID-19. We find that higher levels of risk aversion are associated with risk-reducing behaviors during the COVID-19 pandemic. Meanwhile, we do not find strong evidence that guilt relates to the same behavior.

Locking out prevention: Dental care in the midst of a pandemic

Emergencies, such as natural and manmade disasters, can present an opportunity or be a detriment to preventive healthcare. While stay-at-home orders which some states implemented to mitigate the impact of COVID-19 are known to reduce acute and routine care, little is known about missed preventive care. Dental care, unlike other forms of preventive care - such as pediatric vaccines and well-visits, is simpler to analyze as it is not practicable with telehealth. Using weekly foot traffic data by SafeGraph from January 2018 to June 2020, we examine the effect of stay-at-home orders on visits to dental offices, finding a 15.4% decline after March 2020 for states with stay-at-home orders. Surprisingly, we find that states which allowed dental care during the stay-at-home period experienced a further 7.4% decline in visits. Using Michigan Medicaid dental claims for children we find that the decline of 0.25 claims per month is driven primarily by fewer diagnostic and preventive care visits. Though some preventive visits were rescheduled, we estimate only 58% of visits missed in March and April 2020 were made up by the end of the year. These estimates quantify the short-term declines in preventive dental care, suggesting similar declines in other preventive care.

Pandemics and technology engagement: New evidence from m-Health intervention during COVID-19 in India

Information provision for social welfare via cheap technological media is now a widely available tool used by policymakers. Often, however, an ample supply of information does not translate into high consumption of information due to various frictions in demand, possibly stemming from the pecuniary and non-pecuniary cost of engagement, along with institutional factors. We test this hypothesis in the Indian context using a unique data set comprising 2 million call records of enrolled users of ARMMAN, a Mumbai-based nongovernmental organization that sends timely informational calls to mobile phones of less-privileged pregnant women. The strict lockdown induced by COVID-19 in India was an unexpected shock on engagement with m-Health technology, in terms of both reductions in market wages and increased time availability at home. Using a difference-in-differences design on unique calls tracked at the user-time level with fine-grained time-stamps on calls, we find that during the lockdown period, the call durations increased by 1.53 percentage points. However, technology engagement behavior exhibited demographic heterogeneity increasing relatively after the lockdown for women who had to borrow the phones vis-à-vis phone owners, for those enrolled in direct outreach programs vis-à-vis self-registered women, and for those who belonged to the low-income group vis-à-vis high-income group. These findings are robust with coarsened exact matching and with a placebo test for a 2017-2018 sample. Our results have policy implications around demand-side frictions for technology engagement in developing economies and maternal health.

How does the impact of the COVID-19 state of emergency change? An analysis of preventive behaviors and mental health using panel data in Japan

This study applies the difference-in-difference method on panel data collected from internet surveys to investigate changes in the preventive behaviors and mental health of individuals as influenced by the COVID-19 state of emergency declaration between March and June 2020. The key findings are: (1) The declaration led people to exhibit preventive behaviors but also generated negative emotions; (2) Such behaviors persisted even after deregulation of the state of emergency; (3) Making the declaration early (vs. late) had a larger effect on preventive behavior, with the gap between residents' behaviors for areas that made early vs. late declarations persisting after the deregulation; and (4) The effects on mental health diminished during the state of emergency and disappeared after its deregulation.

Policy Effects of Ecological Red Lines on Industrial Upgrading and Health Promotion: Evidence From China Based on DID Model

The implementation of the Ecological Red Lines (ERL) policy in China is under the background that natural resources have been immoderately exploited for serving rapid economic growth in the last 40 years, where the ecosystem's degradation happened and people's health could be affected. As the secondary industry is the contribution source of rapid growth as well as the threat source that threatens the natural environment and public health, the delimitation of ERL can act as a legal restriction that forces the industries to control the emissions and to upgrade the industrial composition. This paper conducts an ex-post policy evaluation on the improvement effects of industrial structure and residents' health and through ERL's pilot scheme in four provinces of China. By using the difference-in-differences (DID) method, the estimation results show that: (1) The industrial upgrading effect exists but to a small extent, as the ERL policy has generally elevated the tertiary industry's output by only 0.033% and hardly shown any promotion effects on the ratio of the tertiary industry to secondary industry; (2) The residents' health has been significantly improved by 1.029% after ERL policy on the whole, and enhanced over time mostly; (3) The health promotion effects are similar among three out of the four pilot provinces, whereas the industrial upgrading effects performed large heterogeneities among the four. These empirical results may provide references for the wider extension of ERL policy with more practical execution solutions in developing economies.

The effect of resilience on the relationship between perceived stress and change in alcohol consumption during the COVID-19 pandemic in Queensland, Australia

The COVID-19 pandemic has led to increased levels of stress and alcohol consumption. This study examined the effect of resilience on the relationship between stress and changes in alcohol consumption in the context of the COVID-19 pandemic in early 2020. A cross-sectional survey of 502 adults in Queensland, Australia (mean age = 45.68 (16.61)), found 23.9% of individuals had increased their alcohol consumption since the start of the pandemic. Regression modelling demonstrated a significant association between perceived stress and change in alcohol consumption. The study also revealed resilience was a moderating factor, where high levels of resilience buffered against increases in alcohol consumption associated with stress during the COVID-19 pandemic.

What doesn't kill you makes you "smarter": The long-term association between exposure to epidemic and cognition

Emerging epidemics have devastating impacts on people's lives and livelihoods. However, acting as a severe health shock, exposure to an epidemic may induce positive changes in health behaviors among survivors, thereby leading to long-lasting improvement in population health. This study examined the long-term association between exposure to the 2002-2004 severe acute respiratory syndrome outbreak and middle-aged and older Chinese adults' cognition assessed in 2011-2015. Drawing on data from the 2011-2015 China Health and Retirement Longitudinal Study, we found that community exposure to the outbreak was associated with significantly higher scores on episodic memory, after adjusting for demographic characteristics, adulthood socioeconomic status and health, and community socioeconomic conditions. No such a significant association was found for mental intactness. Mediation analysis showed that community exposure to the epidemic was associated with increased participation in social activities, maintaining close family relationships with adult children and grandchildren, and increased participation in regular physical exercise, all of which were positively associated with cognitive functioning in middle-aged and older Chinese adults. These findings suggest that positive post-epidemic behavioral changes are possible and may have long-term health benefits for survivors.

Emotional and financial health during COVID-19: The role of housework, employment and childcare in Australia and the United States

During the first few months of the COVID-19 pandemic, the world witnessed major economic, school, and daycare closures. We sampled respondents in Australia and the US during the height of the first restrictions to understand how the first quarantine structured their emotional strain and financial worry (825 Australians and 835 Americans aged between 18 and 65; May 2-3, 2020; source YouGov). We apply structural equation modeling to demonstrate that the emotional well-being impacts of COVID-19 are not only gendered but also vary between childless people and parents. Specifically, we show that compared to Australians, Americans were more impacted by changes in their financial circumstances. Further, while the financial worry and emotional strain impacts were similar between childless people and parents in Australia, significant differences existed between the two groups in the United States. In particular, we identify American mothers as the most disadvantaged group-feeling the most anxious and financially worried about both employment and domestic changes under COVID-19. Policy wise, we argue that COVID-19 is exacerbating gender inequality in emotional health. To slow down this trend, more adequate mental health supports are needed, particularly for mothers.

The impact of COVID-19 pandemic on insurance demand: the case of China

The COVID-19 has been a worldwide pandemic and it needs for studies related to effect on people's demand for insurance during the pandemic which is an important way to transfer risk. However, there is a lack of research linking COVID-19 and people's demand for insurance. The objective of this paper is to investigate the impact of COVID-19 pandemic on issuance demand, using data covering 241 cities on confirmed COVID-19 cases and insurance company revenue in China. The empirical results show that more confirmed COVID-19 cases are associated with greater per capita insurance revenue and the results are robust when considering endogeneity concern. Economically, the per capita insurance revenue increases by 0.896 Yuan for each more confirmed case. In terms of insurance type, the greatest increased insurance revenue is for life insurance, followed by health insurance. We further consider the heterogeneity of regions and find that the impact of COVID-19 on insurance revenue only exists in regions with worse medical treatment conditions or higher medical burden.

Is Exposure to Epidemic Associated With Older Adults' Health Behavior? Evidence From China's 2002-2004 SARS Outbreak

Objectives

To determine whether exposure to an epidemic is associated with better health behaviors.

Methods

Using nationally representative survey data collected in 2011 and 2014, we identified middle-aged and older Chinese adults whose communities experienced an outbreak of the 2002–2004 severe acute respiratory syndrome (SARS). We estimated logistic models of health behaviors in the years after the SARS epidemic.

Results

Compared to those who lived in communities not hit by the epidemic, respondents who lived in communities with a SARS outbreak in 2002–2004 were more likely to get a physical examination in 2010–2011 and have their blood pressure checked and participate in regular physical exercise in the years following the SARS epidemic. These associations varied by gender and rural–urban residence.

Discussion

Exposure to the SARS epidemic could be positively associated with health behavior among middle-aged and older Chinese adults.

A Bayes Decision Rule to Assist Policymakers during a Pandemic

A new decision rule based on net benefit per capita is proposed and exemplified with the aim of assisting policymakers in deciding whether to lockdown or reopen an economy-fully or partially-amidst a pandemic. Bayesian econometric models using Markov chain Monte Carlo algorithms are used to quantify this rule, which is illustrated via several sensitivity analyses. While we use COVID-19 data from the United States to demonstrate the ideas, our approach is invariant to the choice of pandemic and/or country. The actions suggested by our decision rule are consistent with the closing and reopening of the economies made by policymakers in Florida, Texas, and New York; these states were selected to exemplify the methodology since they capture the broad spectrum of COVID-19 outcomes in the U.S.

Pandemic and hospital avoidance: Evidence from the 2015 Middle East respiratory syndrome outbreak in South Korea

Existing literature shows that people exhibit disease avoidance behaviors in response to contagious disease outbreaks. We examine hospital avoidance behaviors during the 2015 Middle East respiratory syndrome (MERS) outbreak in South Korea. The outbreak provides an excellent setting for the analysis because unlike the coronavirus disease-19 (COVID-19) situation, no mandatory lockdown was imposed during the outbreak, and the economic impact was also not large. Hence, reduced hospital visits are likely to reflect the public's intention to avoid hospitals to protect themselves from getting infected with MERS. Moreover, the outbreak did not spread to the entire country and vanished after a short period of time, allowing us to consider the affected regions as the treatment group and the other regions as the control group without much concern of confounding by other factors. The data come from a government agency, which assesses (national) health insurance claims made by hospitals, and hence cover all outpatient visits in the country. We find that people reduced outpatient visits by about 17% in response to the MERS outbreak, and the response was the most intense when new cases were reported most frequently.

Behavioral responses to the 2015 MERS epidemic in Korea

Understanding behavioral responses to epidemics is important in evaluating the broad health consequences of emerging infectious diseases. Building on the economic epidemiology literature, this study investigates individual behavioral responses to the 2015 Middle East Respiratory Syndrome Coronavirus (MERS-CoV) epidemic in Korea using a panel of individuals in a nationally representative survey. Results show that exposure to the epidemic led to lasting impacts on smoking and drinking behaviors, indicating that emerging infectious disease outbreaks are motivations for behavioral changes and opportunities for public policy interventions. In particular, individuals in the hardest-hit regions or socially connected persons were more likely to change their risky behaviors, suggesting that intensity of exposure and social interactions are potential mechanisms.

Water, Sanitation, and Hygiene Practices and Challenges during the COVID-19 Pandemic: A Cross-Sectional Study in Rural Odisha, India

Water, sanitation, and hygiene (WASH) practices emerged as a critical component to controlling and preventing the spread of the COVID-19 pandemic. We conducted 131 semistructured phone interviews with households in rural Odisha, India, to understand behavior changes made in WASH practices as a result of the pandemic and challenges that would prevent best practices. Interviews were conducted from May through July 2020 with 73 heads of household, 37 caregivers of children < 5 years old, and 21 members of village water and sanitation committees in villages with community-level piped water and high levels of latrine ownership. The majority of respondents (86%, N = 104) reported a change in their handwashing practice due to COVID-19, typically describing an increase in handwashing frequency, more thorough washing method, and/or use of soap. These improved handwashing practices remained in place a few months after the pandemic began and were often described as a new consistent practice after additional daily actions (such as returning home), suggesting new habit formation. Few participants (13%) reported barriers to handwashing. Some respondents also detailed improvements in other WASH behaviors, including village-level cleaning of water tanks and/or treatment of piped water (48% of villages), household water treatment and storage (17% of respondents), and household cleaning (41% of respondents). However, there was minimal change in latrine use and child feces management practices as a result of the pandemic. We provide detailed thematic summaries of qualitative responses to allow for richer insights into these WASH behavior changes during the pandemic. The results also highlight the importance of ensuring communities have adequate WASH infrastructure to enable the practice of safe behaviors and strengthen resilience during a large-scale health crisis.

Determinants of the community mobility during the COVID-19 epidemic: The role of government regulations and information

This paper studies the dynamics of human mobility during the initial stage of the COVID-19 pandemic in countries around the world. The main goal of the analysis is to empirically separate voluntary reductions in mobility driven by the information about the location-specific pandemic trends from the effects of the government-imposed social distancing mandates. Google human mobility dataset is used to track the dynamics of mobility across a wide range of categories (e.g., workplace, retail and recreational activities, etc.), while information on country-specific counts of COVID-19 cases and deaths is used as a proxy for the information about the spread of the pandemic available to the population. A detailed index of stringency of the government-imposed social distancing policies in around 100 countries is used as a measure of government response. We find that human mobility does respond in a significant way to the information about the spread of the pandemic. This channel can explain about 15 percentage points of the overall reduction in mobility across the affected countries. At the same time, our results imply that government-imposed policies account for the majority of the reduction in the mobility observed during this period.

Rolling back the gains: Maternal stress undermines pregnancy health after Flint's water switch

Environmental disasters impact disadvantaged communities disproportionately both through the epidemiological challenge of exposure, but also by undermining the progress of public health efforts. This paper studies changes to smoking cessation, breastfeeding, and weight gain during pregnancy in the period following the switch in water supply in Flint, Michigan, in April 2014. As the switch resulted in immediate and significant deterioration in water quality, eventually leading to its contamination with lead, we estimate a 10.5 percentage point increase in smoking and a 2.1 percentage point decrease in breastfeeding. We show evidence that these changes in maternal behavior are linked to increased stress due to changing water quality. We estimate that the increase in smoking alone is responsible for most of the increase in incidence of low birthweight among infants in Flint, resulting in $700 additional costs per birth. Increased smoking during pregnancy and lower breastfeeding rates in Flint roll back years of public health efforts, resulting in lifetime higher rates of cardiovascular disease, diabetes, and cancer for mothers in the community.

Water, sanitation, and hygiene practices and challenges during the COVID-19 pandemic: a cross-sectional study in rural Odisha, India

Water, sanitation, and hygiene (WASH) practices emerged as a critical component to controlling and preventing the spread of the COVID-19 pandemic. We conducted 131 semi-structured phone interviews with households in rural Odisha, India to understand behavior changes made in WASH practices as a result of the pandemic and challenges that would prevent best practices. Interviews were conducted from May-July 2020 with 73 heads of household, 37 caregivers of children less than five years old, and 21 members of village water and sanitation committees in villages with community-level piped water and high levels of latrine ownership. The majority of respondents (86%, N=104) reported a change in their handwashing practice due to COVID-19 or the related government lockdown, typically describing an increase in handwashing frequency, more thorough washing method, and/or use of soap. These improved handwashing practices remained in place a few months after the pandemic began and were often described as a new consistent practice after additional daily actions (such as returning home), suggesting new habit formation. Few participants (13%) reported barriers to handwashing. Some respondents also detailed improvements in other WASH behaviors including village-level cleaning of water tanks and/or treatment of piped water (48% of villages), household water treatment and storage (17% of respondents), and household cleaning (41% of respondents). However, there was minimal change in latrine use and child feces management practices as a result of the pandemic. We provide detailed thematic summaries of qualitative responses to allow for richer insights into these WASH behavior changes, or lack thereof, during the pandemic. The results also highlight the importance of ensuring communities have adequate WASH infrastructure to enable the practice of safe behaviors and strengthen resilience during a large-scale health crisis.

Health Shocks and Unbalanced Growth of Medical Resources: Evidence From the SARS Epidemic in China

Since the outbreak of the SARS epidemic in 2003, the Chinese government has increased inputs to bolster the health care system. However, the COVID-19 pandemic has exposed the geographic maldistribution of health resources in China. We examine the spatial and temporal variation of the SARS epidemic using a difference-in-differences strategy. Our empirical results show that, compared with cities without SARS case reports, exogenous health shocks significantly increased the affected cities' medical resources supply. We provide multiple robustness tests to examine the validity of the main findings. Further study shows that the mechanism is because the SARS event increased the financial autonomy of the epidemic-affected cities, thus providing an incentive for local governments to increase health resources. Meanwhile, health shocks have little influence on the regions with only imported cases than the infected area. These findings provide a possible explanation for the inequality in the distribution of health resources.

When less is more: Can reduced health monitoring improve medication adherence?

As the prevalence of chronic diseases rises, improving self-management has become an important determinant of the productivity of healthcare delivery. Recently, Mexico's largest healthcare provider began issuing automatic-refill prescriptions to stable hypertensive patients, thus reducing the frequency of health monitoring from 30- to 90-day intervals. Exploiting this change, I find that less monitoring implies no drawbacks in health outcomes and actually improves self-management of disease by increasing medication adherence when baseline monitoring is relatively frequent. The number of days when patients are out of medication between fillings falls by 2.2 days-an improvement in adherence of 6.4%. Furthermore, patients appear to value being on a low-frequency regime as they improve adherence in order to remain on it, suggesting that lower monitoring could be used as a "reward" to promote medication adherence or, potentially, other health behaviors. Finally, I find evidence of positive spillovers on adherence, as clinic congestion falls.

Do memories of the Ebola virus disease outbreak influence post-Ebola health seeking behaviour in Guéckédou district (epicentre) in Guinea? A cross-sectional study of children with febrile illness

BACKGROUND

The 2013-2015 Ebola Virus Disease (EVD) outbreak in Guinea resulted in community mistrust that influenced health care service utilization. This study aimed to assess whether EVD-related memories affect post-outbreak health-seeking behaviours for children under 5 years of age with febrile illnesses in Guéckédou district, Guinea.

METHODS

This cross-sectional study was conducted by surveying caregivers of children under 5 years of age in the sub-district most affected by the EVD outbreak (Guèndembou) and the least affected sub-district (Bolodou) in Guéckédou district. Memories of the outbreak were referred to as EVD-related fears in the post-EVD period, which was based on a series of questions regarding current feelings.

RESULTS

While the majority of caregivers sought care for their children with febrile illness in both districts, a statistically significantly higher proportion of caregivers in Guèndembou sought care, compared to caregivers in Bolodou.. More caregivers in Guèndembou (19.9%; n = 39) reported the death of family members or friends due to EVD compared to Bolodou (6.9%; n = 14; P < 0.001). The mean EVD fear score of caregivers was significantly higher in Guèndembou (3.0; SD: 3.0) than in Bolodou (2.0; SD: 1.1) (p < 0.001). Caregivers with a fear score above the median were 1.68 times more likely to seek care than those whose fear score was equal to or below the median; however, this difference was not statistically significant. Caregivers who reported family members' or friends' death due to EVD were also more likely to seek care (AOR = 2.12; 95%CI: 0.91-4.91), however, with no statistical significance. Only residing in the EVD-most affected sub-district of Guèndembou (AOR = 1.74; 95%CI: 1·09-2.79) was positively associated with seeking care.

CONCLUSIONS

This study reveals that community members in the rural district of Guéckédou still live with fear related to EVD nearly 2 years after the outbreak. It calls for more efforts in the health domain to preserve communities' key values and address the psychosocial effect of EVD in rural Guinea.

The WASH Benefits and SHINE trials: interpretation of WASH intervention effects on linear growth and diarrhoea

Child stunting is a global problem and is only modestly responsive to dietary interventions. Numerous observational studies have shown that water quality, sanitation, and handwashing (WASH) in a household are strongly associated with linear growth of children living in the same household. We have completed three randomised efficacy trials testing improved household-level WASH with and without improved infant and young child feeding (IYCF) on stunting and diarrhoea in Bangladesh, Kenya, and Zimbabwe. In all trials, improved IYCF had a statistically significant benefit, but WASH had no effect on linear growth. In observational analyses of data from the control groups of the three trials, baseline sanitation was a strong risk factor for stunting in the study populations, suggesting this frequently reported association might be confounded by unmeasured factors of household wellbeing. WASH interventions reduced diarrhoea in Bangladesh, but not in Kenya or Zimbabwe. Intervention promoters visited participants six times per month in Bangladesh compared with monthly in Kenya and Zimbabwe; a review of the literature shows that virtually all published studies that have reported an effect on diarrhoea through home-based water treatment and handwashing promotion achieved high adherence by visiting participants at daily to fortnightly intervals. Despite achieving substantial behavioural change and significant reduction in infection prevalence for some enteric pathogens, detection of enteropathogens among children in the WASH groups of the trials was typically at ten times higher prevalence compared with high-income countries. Considering these results, we recommend that future research in the WASH sector focus on developing and evaluating interventions that are radically more effective in reducing faecal contamination in the domestic environment than the interventions implemented in these trials.

Effects of Physical Distancing to Control COVID-19 on Public Health, the Economy, and the Environment

Physical distancing measures are important tools to control disease spread, especially in the absence of treatments and vaccines. While distancing measures can safeguard public health, they also can profoundly impact the economy and may have important indirect effects on the environment. The extent to which physical distancing measures should be applied therefore depends on the trade-offs between their health benefits and their economic costs. We develop an epidemiological-economic model to examine the optimal duration and intensity of physical distancing measures aimed to control the spread of COVID-19. In an application to the United States, our model considers the trade-off between the lives saved by physical distancing-both directly from stemming the spread of the virus and indirectly from reductions in air pollution during the period of physical distancing-and the short- and long-run economic costs that ensue from such measures. We examine the effect of air pollution co-benefits on the optimal physical distancing policy and conduct sensitivity analyses to gauge the influence of several key parameters and uncertain model assumptions. Using recent estimates of the association between airborne particulate matter and the virulence of COVID-19, we find that accounting for air pollution co-benefits can significantly increase the intensity and duration of the optimal physical distancing policy. To conclude, we broaden our discussion to consider the possibility of durable changes in peoples' behavior that could alter local markets, the global economy, and our relationship to nature for years to come.

Change in Physical Activity after Diagnosis of Diabetes or Hypertension: Results from an Observational Population-Based Cohort Study

Background: Chronic diseases like diabetes mellitus or hypertension are a major public health challenge. Irregular physical activity (PA) is one of the most important modifiable risk factors for chronic conditions and their complications. However, engaging in regular PA is a challenge for many individuals. The literature suggests that a diagnosis of a disease might serve as a promising point in time to change health behavior. This study investigates whether a diagnosis of diabetes or hypertension is associated with changes in PA. Methods: Analyses are based on 4261 participants of the population-based KORA S4 study (1999–2001) and its subsequent 7-and 14-year follow-ups. Information on PA and incident diagnoses of diabetes or hypertension was assessed via standardized interviews. Change in PA was regressed upon diagnosis with diabetes or hypertension, using logistic regression models. Models were stratified into active and inactive individuals at baseline to avoid ceiling and floor effects or regression to the mean. Results: Active participants at baseline showed higher odds (OR = 2.16 [1.20;3.89]) for becoming inactive after a diabetes diagnosis than those without a diabetes diagnosis. No other significant association was observed. Discussion: As PA is important for the management of diabetes or hypertension, ways to increase or maintain PA levels in newly-diagnosed patients are important. Communication strategies might be crucial, and practitioners and health insurance companies could play a key role in raising awareness.

Risk and Response to Biological Catastrophe in Lower Income Countries

Natural and intentional biological risks threaten human civilization, both through direct human fatality as well as follow-on effects from a collapse of the just-in-time delivery system that provides food, energy and critical supplies to communities globally. Human beings have multiple innate cognitive biases that systematically impair careful consideration of these risks. Residents of low-income countries, especially those who live in rural areas and are less dependent upon global trade, may be the most resilient communities to catastrophic risks, but low-income countries also present a heightened risk for biological catastrophe. Hotspots for the emergence of new zoonotic diseases are predominantly located in low-income countries. Crowded, poorly supplied healthcare facilities in low-income countries provide an optimal environment for new pathogens to transmit to a next host and adapt for more efficient person-to-person transmission. Strategies to address these risks include overcoming our natural biases and recognizing the importance of these risks, avoiding an over-reliance on developing specific biological countermeasures, developing generalized social and behavioral responses and investing in resilience.