Decision-making under uncertainty in environmental health policy: new approaches

Examining Perceptions of Uncertain Language in Potential E-Cigarette Warning Labels: Results from 16 Focus Groups with Adult Tobacco Users and Youth

E-cigarette use among youth presents a public health risk. Yet, cigarette smokers who substantially reduce their smoking or switch completely from traditional combustible cigarettes could benefit. As science about e-cigarettes is continually emerging, any potential warnings are likely to contain uncertain language. Hedged verbiage may impact decision making. To assess reactions, we conducted 16 online focus groups; 8 with youth (n = 32, grouped by gender and by vaping experience) and 8 with adult tobacco users (n = 37, grouped by smokers, dual users of e-cigarettes and cigarettes, and former smokers who switched to e-cigarettes). Each focus group viewed and discussed 8 potential warnings messages. We conducted an inductive thematic analysis of the reactions to warning messages that contain uncertain language. Respondents' reactions were often negative, but varied based on specific usages of uncertainty, existing beliefs about uncertainty in law and science, and smoking/vaping use patterns that supported the use of uncertainty related to e-cigarettes. Many youth (and some adults) believed that uncertain language enabled audiences to minimize the likelihood of harm or interpreted it as meaning there are both healthy and unhealthy e-cigarettes. This qualitative study provides evidence that the use of types of uncertain language, the frequency of that use, and/or the selection of particular words in warnings, might not achieve the intended public health aims of increasing understanding of risk, deterring youth uptake, and/or facilitating a substantial switch from cigarettes. The use of certain types of uncertain language appears to have significant potential to bring unintended consequences. Suggestions for research and policy are included.

Developing and validating of the Clinical Uncertainty Measurement Questionnaire (CUMQ) among practicing physicians and clinical residents in Iran

BACKGROUND

Despite the fact that clinicians face uncertainty in their decisions, there is no comprehensive framework to measure it in medical practices which is the knowledge gap especially for Iran. Therefore, this study aimed to evaluate the reliability and validity of a Persian questionnaire which is designed to measure different determining aspects of uncertainty from clinical physicians' perspectives in Iran.

METHODS

Clinical Uncertainty Measurement Questionnaire (CUMQ) has been derived from a mixed method study since March 2019 to January 2021. To exclude raw items of the questionnaire, the literature was reviewed and in-depthinterviews were implemented with 24 residents,specialists and sub-specialists in all major clinical fields which resulted in the first theoretical uncertainty in clinical decision making framework. CUMQ content validity has been evaluated using content validity index (CVI) and content validity ratio (CVR). The structural validity of the questionnaire was assessed using confirmatory factor analysis and factor loading and t-value for each indicator of uncertainty is reported. Moreover, to analyze the research model we used the Partial Least Squares (PLS) technique using the SmartPLS software. Convergent (using Average Variance Extracted (AVEs) for each latent variable) and discriminant validity (using the criteria of Fornell and Larckerand cross loading) of the model was also evaluated. After that, the quality of the model was evaluated adjustment through predictive validity (Q²) and effect size (f²). In addition, the reliability was also assessed using Cronbach's alpha and composite reliability.

RESULTS

The CVR and CVI ranged from 0. 80 to 1. 00 which illustrates high content validity. Out of 30 items, 24 items had acceptable factor loading and remained in the questionnaire which have been categorized as five main clinical uncertainty dimensions; general determinants, individual determinants of the physician, individual determinants of patient, dynamics of medical sciences, diagnostic and instrumental limitations. The value of composite reliability and Cronbach's alpha for all dimensions were above the threshold value of 0. 7 and the reliability has been confirmed. As AVE values were greater than 0. 5, convergent validity is confirmed. The result of Fornell-Larcker and cross-loadings also indicated that discriminant validity is well established.

CONCLUSION

This CUMQ is as avalid and reliable instrument and a suitable tool to measure clinical uncertainty in the Iranian Medical community. However, the reliability of this questionnaire can be studied in other languages and in other countries.

The Covid-19 pandemic, an Environmental Neurology perspective

Neurologists have a particular interest in SARS-CoV-2 because the nervous system is a major participant in COVID-19, both in its acute phase and in its persistent post-COVID phase. The global spread of SARS-CoV-2 infection has revealed most of the challenges and risk factors that humanity will face in the future. We review from an environmental neurology perspective some characteristics that have underpinned the pandemic. We consider the agent, SARS-CoV-2, the spread of SARS-CoV-2 as influenced by environmental factors, its impact on the brain and some containment measures on brain health. Several questions remain, including the differential clinical impact of variants, the impact of SARS-CoV-2 on sleep and wakefulness, and the neurological components of Long-COVID syndrome. We touch on the role of national leaders and public health policies that have underpinned management of the COVID-19 pandemic. Increased awareness, anticipation and preparedness are needed to address comparable future challenges.

Interrupting vaccination policies can greatly spread SARS-CoV-2 and enhance mortality from COVID-19 disease: The AstraZeneca case for France and Italy

Several European countries have suspended the inoculation of the AstraZeneca vaccine out of suspicion that it causes deep vein thrombosis. In this letter, we report some Fermi estimates performed using a stochastic model aimed at making a risk-benefit analysis of the interruption of the delivery of the AstraZeneca vaccine in France and Italy. Our results clearly show that excess deaths due to the interruption of the vaccination campaign injections largely overrun those due to thrombosis even in worst case scenarios of frequency and gravity of the vaccine side effects.

Reduction in inequalities in health insurance coverage and healthcare utilization among older adults in the Philippines after mandatory national health insurance coverage: trend analysis for 2003-2017

BACKGROUND

Health policies in the Philippines have evolved in response to increasing health demands of older adults. However, there is a lack of research on equity among the ageing population in low-middle income countries. The objective of this study was to identify the trends in National Health Insurance Program (NHIP) coverage and healthcare utilization among older adults in the Philippines for the period from 2003 to 2017, during which NHIP expansion policies were implemented, focusing on reductions in socio-economic inequalities.

METHODS

A literature search of policies for older adults and an analysis of four Philippine National Demographic and Health Surveys (2003, 2008, 2013, and 2017) with data from 25,217 older adults who were 60 years or older were performed. The major outcome variables were NHIP coverage, self-reported illness, outpatient healthcare utilization, and inpatient healthcare utilization. Inequalities in NHIP coverage and healthcare utilization according to wealth were evaluated by calculating the concentration index for individual years, followed by a regression-based decomposition analysis.

RESULTS

NHIP coverage among older adults increased from 9.4 (2003) to 87.6% (2017). Although inequalities according to wealth quintile were observed in all four surveys (all P < 0.001), the concentration index declined from 0.3000 (2003) to 0.0247 (2017), showing reduced inequalities in NHIP coverage over time as observed for self-reported illness and healthcare utilization. NHIP coverage expansion for older adults in 2014 enabled equal opportunity for access to healthcare.

CONCLUSION

The passage of mandatory NHIP coverage for older Filipino adults in 2014 was followed by a reduction in inequality in NHIP coverage and healthcare utilization according to wealth.

Exploring the non-technical competencies for on-scene public health responders in chemical, biological, radiological, and nuclear emergencies: a qualitative study

Objectives

The purpose of this study was to define and delineate specific non-technical competencies for first-line public health responders in Chemical, Biological, Radiological, and Nuclear (CBRN) emergencies in China.

Study design

A qualitative study was conducted in China involving interviews with key informants in the field of health response to CBRN disasters.

Methods

One-on-one in-depth interviews were carried out with 20 participants, including expert members of National Medical Response Teams for CBRN disasters, officials at emergency management authorities, and scholars of academic institutions related to CBRN emergency. Interviews were recorded using audio equipment, transcribed, and coded into codable passages as per grounded theory using NVivo software. Themes were identified within the transcriptions by using thematic analysis.

Results

A total of 159 codable passages were produced. Eight domains of non-technical core competencies were identified: (1) situation awareness, (2) communication skills, (3) collaboration, (4) resource management, (5) task management, (6) cultural competency, (7) austere environment skills, and (8) physical stamina.

Conclusions

The study identified a variety of competencies for on-scene public health responders in CBRN emergencies. The findings of this study could specifically benefit development of strategy and improvement of content of education and training. Further research that involves input from the disaster response community at large is needed for the validation of these competencies.

•

Non-technical competencies affect performance of health response to Chemical, Biological, Radiological, and Nuclear (CBRN) disasters.

•

Austere environment skills and physical stamina are priority non-technical competencies for on-site public health responders in CBRN events.

•

Effective CBRN health emergency training should integrate and synchronize courses based on non-technical/technical competency.

The relationship between metabolic syndrome and the incidence of colorectal cancer

OBJECTIVES

This study evaluated the incidence of colorectal cancer (CRC) according to the number of metabolic syndrome (MetS) components.

METHODS

Using health checkup and insurance claims data of 6,365,409 subjects, the occurrence of CRC according to stage of MetS by sex was determined from the date of the health checkup in 2009 until December 31, 2018.

RESULTS

Cumulative incidence rates (CIR) of CRC in men and women was 3.9 and 2.8 per 1000 (p < 0.001), respectively. CIR of CRC for the normal, pre-MetS, and MetS groups in men was 2.6, 3.9, and 5.5 per 1000 (p < 0.001) and CIR in women was 2.1, 2.9, and 4.5 per 1000 (p < 0.001), respectively. Compared with the normal group, the hazard ratio (HR) of CRC for the pre-MetS group was 1.25 (95% CI 1.17-1.33) in men and 1.09 (95% CI 1.02-1.17) in women, and the HR of CRC for the MetS group was 1.54 (95% CI 1.43-1.65) in men and 1.39 (95% CI 1.26-1.53) in women after adjustment.

CONCLUSIONS

We found that MetS is a risk factor for CRC in this study. Therefore, the prevention and active management of MetS would contribute to the prevention of CRC.