Objectives Outbreaks are associated with increased risk of anxiety disorders, depression, and severe mental conditions. Integrating mental health and psychosocial support (MHPSS) into outbreak response facilitates the delivery of holistic care to the affected community. As there is an increasing incidence of outbreaks globally, integrating MHPSS into preparedness and response plans is paramount to strengthen the capacity of existing health systems and respond to mental health and psychosocial needs. However, the attention given to MHPSS during outbreak response is critically low. The objectives of this study were to identify areas of MHPSS integration and explore the challenges that hinder the delivery of an integrated care during outbreak response. Methods A participatory qualitative study was conducted to explore how MHPSS can be incorporated into outbreak preparedness and response plans as a cross-cutting intervention in the context of low- and middle-income countries. We brought together civil society representatives, key stakeholders, and public health experts to explore areas of MHPSS integration during outbreak response. Results Systematic integration of MHPSS into outbreak response was perceived to be feasible. Study participants strongly agreed that MHPSS can be integrated into most of the outbreak response pillars including partner coordination, case management, infection prevention and control, staff health and well-being, and risk communication and community engagement. However, the effort requires multi-sectoral collaboration, political commitment, and adequate recognition in planning and financing. Conclusions Despite complex challenges, integrating MHPSS into outbreak pillars is possible. Moreover, emphasis should be placed on cultural adaptation of MHPSS guidelines and strong leadership in coordinating MHPSS into outbreak planning and response.

Compared with other OECD countries, Bermuda ranks third globally in terms of income inequality globally. During the COVID-19 pandemic, anecdotal evidence suggested, significant fluctuations in the food demand and supply. We aimed to examine the impact of the COVID-19 pandemic on food insecurity, with a focus on the availability and affordability of various foods in Bermuda. We utilized a cross-sectional study design to investigate potential drivers of food insecurity within the local population. To gauge the level of household food insecurity we relied on the Bermuda Omnibus survey (N = 400) undertaken by Total Research Associates Ltd via telephone. To assess changes in food availability and affordability we conducted semi-structured interviews with key stakeholders who played pivotal roles in shaping food accessibility availability and affordability of food in Bermuda. These interviews were systematically analysed using the framework method. We performed analyses of food retail and import data to evaluate fluctuations in food prices and their impact on food availability and affordability. We found statistically significant associations between changes in food consumption, household income, and government aid. Food aid beneficiaries ate fewer fruits and vegetables by 50% [95% CI:17%-83%] and less fresh meat and fish by 39% [95 CI:3%-75%] compared with residents who did not receive any aid during the COVID-19 period from March 2020 to March 2021. Although we did not identify statistically significant food price increases feeding programmes played a pivotal role in preventing food insecurity during the pandemic in Bermuda. However, a lack of monitoring regarding the nutritional quality within the programmes, allowed a wide availability of foods high in sugar, salts, and fats, disproportionately affected low-income populations. In conclusion, food availability in Bermuda remained largely unaffected during the pandemic. Nevertheless, the surge in demand for feeding programs underscores underlying food security challenges in Bermuda and warrants further attention.

Background The small Atlantic island of St Helena is a United Kingdom Overseas Territory (UKOT) with a high prevalence of childhood obesity (over a quarter of 4-5 and 10-11 year olds) and, anecdotally, adulthood obesity and its associated health detriments. St Helena have taken a whole systems approach to obesity (WSAO) to address the issue. A WSAO recognises the factors that impact obesity as a complex system and requires a 'health in all policies' approach. UK academic and public health technical support was provided to the local St Helena delivery team. This process evaluation sought to explore the early stages of the WSAO implementation and implications for the transferability of the approach to other small island developing states and UKOT.Methods Data was collected via eight semi-structured interviews, paper based and online surveys, and document analysis. Thematic analysis was used to analyse the data.Results The analysis identified three factors which aided the first phase of WSAO implementation: (1) senior leaders support for the approach; (2) the academic support provided to establish and develop the approach; and (3) effective adaptation of UK Government resources to suit the local context. Key challenges of early implementation included: maintaining and broadening stakeholder engagement; limited local workforce capacity and baseline knowledge related to obesity and systems thinking; and limited capacity for support from the UK-based academic team due to contract terms and COVID-19 restrictions.Conclusions Early stages of implementation of a WSAO in a UKOT can be successful when using UK's resources as a guide and adapting them to a small island context. All participants recommended other small islands adopt this approach. Continued senior support, dedicated leadership, and comprehensive community engagement is needed to progress implementation and provide the foundation for long-term impact. Small island developing states considering adopting a WSAO should consider political will, senior level buy-in and support, funding, and local workforce knowledge and capacity to enable the best chances of successful and sustainable implementation.

INTRODUCTION:Depression associated with chronic illnesses is common in Southern Africa, yet there are major treatment gaps. This study assesses the feasibility and acceptability of the Healthy Activity Program intervention for depression among people with HIV and/or TB. The intervention involves training nonspecialist nurses in depression, including identification, counseling based on behavioral activation theory, and structured referral. METHODS:This is a mixed methods evaluation of a pilot counseling service integrated within routine HIV and TB care from 2018 to 2019. Participants included people living with HIV and/or patients with TB in rural Eswatini. RESULTS:A total of 324 people living with HIV and/or TB were screened for depression, with 19% (62/324) screening positive. The median number of sessions attended was 3 (interquartile range: 1-5), with 16/60 (26%) attending the minimum 5 sessions. Qualitative results indicated acceptability, but there were concerns about feasibility. CONCLUSIONS:The Healthy Activity Program is a promising option to manage the treatment gap for depression in people with HIV and/or TB. However, task-shifting to nonspecialist health care professionals without increasing staff capacity is a barrier to implementation. Realistic and pragmatic assessments of capacity and workforce are essential.

COVID-19 vaccine hesitancy has previously been modelled using data on intentions - expressed prior to vaccine availability. Once vaccines became widely available, it became possible to model hesitancy using actual vaccination uptake data. This paper estimates the determinants of the joint distribution of COVID-19 vaccination intentions (declared before the release of any vaccine) and actual vaccination take-up (when it was widely available across the age distribution). We use high quality longitudinal data (UK Household Longitudinal Study) collected during the pandemic in the UK, merged to a wide variety of individual characteristics collected prior to the COVID-19 pandemic. Our estimation draws on pre-Covid values of variables for a sample that includes 10,073 observations from the September 2021 wave. The contribution of this paper is to model hesitancy and uptake jointly. The work shows that people who might be regarded as marginalised in society (measured, before the pandemic began) are less likely to say that they intend to be vaccinated and they go on to also be more likely to actually remain unvaccinated. It also shows that there is a large positive correlation between the unobservable determinants of intention and of uptake. This high positive correlation has an important implication - that information campaigns can be reasonably well profiled to target specific groups on the basis of intention data alone. We also show that changing one's mind is not correlated with observable data. This is consistent with two explanations. Firstly, the new information available on the arrival of vaccines, that they are safe and effective, may be more optimistic than was originally assumed. Secondly, individuals may have been more pessimistic about the effects associated with infection before vaccines became available.

Background Small island developing states (SIDS) have particular mental health system needs due to their remoteness and narrow resource base. We conducted situational analyses to support mental health system strengthening in six SIDS: Anguilla, Bermuda, British Virgin Islands, Cayman Islands, Montserrat and Turks and Caicos Islands. Methods The situational analyses covered five domains: 1. Socio-economic context and burden of mental disorders, 2. Leadership and governance for mental health 3. Mental health and social care services 4. Strategies for promotion and prevention in mental health and 5. Information systems, evidence and research for mental health. First, a desk-based exercise was conducted, in which data was drawn from the public domain. Second, a field visit was conducted at each site, comprising visits to facilities and consultation meetings with key stakeholders. Results Our key findings were 1. Despite most of these SIDS being high-income economies, social inequalities within states exist. There was no population-level data on mental health burden. 2. All SIDS have a mental health policy or plan, but implementation is typically limited due to lack of funds or staff shortages. There was minimal evidence of service user involvement in policy or service development. 3. All SIDS have a specialist, multi-disciplinary mental health workforce, however Montserrat and Anguilla rely on visiting psychiatrists. Child and adolescent and dedicated crisis intervention services were found in only two and one SIDS respectively. A recovery-oriented ethos was not identified in any SIDS. 4. Mental illness stigma was prevalent in all SIDS. Promotion and prevention were objectives of mental health strategies for all SIDS, however activities tended to be sporadic. No mental health non-Governmental organisations were identified in three SIDS. 5. Health information systems are generally underdeveloped, with paper-based systems in three SIDS. There has been no rigorous local mental health research. Conclusion Cross-cutting recommendations include: to develop mental health action plans that include clear implementation indicators; to facilitate community surveys to ascertain the prevalence of mental disorders; to explore task-sharing approaches to increase access to primary mental health care; and to develop programmes of mental health promotion and prevention.

This research aimed to (1) assess the extent to which mental health and psycho-social support (MHPSS) was included in the national response to the COVID-19 pandemic in African countries, and (2) explore barriers and enablers to MHPSS integration into the COVID-19 response. A mixed-methods study, using an online survey and in-depth interviews, was conducted. Participants included Mental Health Focal Points at the Ministries of Health, the World Health Organization (WHO) country and regional offices, and civil society representatives. Responses were received from 28 countries out of 55 contacted. The implementation level, based on standard guidelines, of MHPSS activities was below 50% in most countries. The most implemented MHPSS activities were establishing coordination groups (57%) and developing MHPSS strategy (45%), while the least implemented activities included implementing the developed MHPSS strategy (32%) and establishing monitoring and evaluation mechanisms (21%). Key factors that hindered implementing MHPSS activities included lack of political commitment and low prioritisation of mental health during emergencies, as it was seen as a "less important" issue during the COVID-19 pandemic, when more importance was given to infection prevention and control (IPC). However, there are signs of optimism, as mental health gained some attention during COVID-19. It is imperative to build on the attention gained by integrating MHPSS in emergency preparedness and response and strengthening mental health systems in the longer term.

We show that a Scottish policy reform, which introduced free formal personal home care for those aged 65 and above, reduced the probability and the hours of receiving informal personal care. Moreover, we find that the group of individuals that most benefited from the policy introduction, i.e. women aged 75 and above, experienced the largest fall in informal care. We go on to investigate whether such reductions in informal and increases in formal personal care impacted on the care recipients' health outcomes. Our results demonstrate that switching from informal to formal care does very little to the recipients' hospital usage and health outcomes.

We examine the effect of attending academically selective high schools on test scores, by leveraging administrative data that matches high school preferences of the population of urban middle school graduates in one Chinese prefecture in 2010 with high school student records. The standard admission channel is generally driven by merit subject to only nominal tuition fees, with contextual admission for disadvantaged students. An alternative admission channel admits lower-ability students subject to substantial selection-fees, retained by the under-funded schools. We combine a cumulative multiple-cutoff regression discontinuity design (RDD) with a within-cutoff normalizing-and-pooling fuzzy RDD strategy, based on publicly announced school-specific admission thresholds in the city-wide High School Entrance Exam (HSEE) scores. Multiple-cutoff RDD estimates show heterogeneous effects of attending schools with different degrees of selectivity, in a unified setting. Within-cutoff normalizing-and-pooling RDD allows admission thresholds to differ by willingness to pay the extra selection-fees and by eligibility for contextual admission. The estimated effects on high school leaving exam scores of attending elite schools vs normal public high schools, and of attending normal public high schools vs low-quality private high schools are insignificantly different from zero, for students who barely made it into the more selective school. However, the effect of attending the most selective flagship school vs elite schools, has a large negative and statistically significant effect, which is more pronounced for girls, for students from the semi-urban area according to hukou (household) registration, and for students who performed relatively badly in the science track subjects in the HSEE.

This paper investigates the impact of introducing universal free formal personal care on informal caregiving behaviour in Scotland - in particular, we explore the extent to which free formal care might crowd out the supply of informal care. We estimate, in a difference-in-differences framework, that such a reform would: reduce the probability of co-residential informal caregiving (usually, provided by spouses) by around 18% and, conditional on co-residential caring, reduce such informal care by 1.3 hours per week. These estimates suggest that an additional hour of formal care displaces approximately 1 hour of such informal care. However, we find no displacement effect on extra-residential informal caring (often supplied by adult daughters). We also find evidence of increases in labour market participation and hours worked.

We use a large and novel administrative dataset to investigate returns to different university 'degrees' (subject-institution combinations) in the United Kingdom. Conditioning on a rich set of background characteristics, we find substantial variation in returns across degrees with similar selectivity levels, suggesting students' degree choices matter a lot for later-life earnings. Returns increase with university selectivity much more at the top of the selectivity distribution than further down, and much more for some subjects than others. Returns are poorly correlated with observable degree characteristics other than selectivity, which could have important implications for student choices and the incentives of universities.

To investigate the clinical influence of Alzheimer's disease (AD) co-pathology on motor features in Lewy Body Dementia (LBD).

Background: Depression and comorbidity with chronic illnesses is common in Southern Africa, yet there are major treatment gaps. This study evaluates the intervention ‘Healthy Activity Program’ to bridge this gap, which involves training non-specialist nurses in depression: including identification, counselling based on behavioural activation theory and structured referral. This intervention aims to be integrated into routine primary healthcare services for HIV/TB. The patient cohort were people living with HIV and/or tuberculosis (TB) (PLHIV/TB) in rural Eswatini. Aims: To assess the feasibility and acceptability of this intervention and concepts of depression in this setting.Methods: This is a pragmatic mixed methods evaluation of a pilot integrated service. Results: 324 PLHIV/TB were screened for depression, with 19% (62/324) screening positive. Attendance to counselling declined over time, with 16/62 attending the minimum 5 sessions. Qualitative results indicated acceptability, yet concerns around feasibility. Conclusions: The ‘Healthy Activity Program’ represents a promising option to manage the treatment gap for depression in PLHIV/TB. However, task-shifting onto non-specialist healthcare professionals with the aim to integrate care for these conditions in primary care, without increasing staff capacity, is a barrier to implementation. Realistic and pragmatic assessments of capacity and workforce are essential.

Background Social circumstances in which people live and work impact the population’s mental health. We aimed to synthesise evidence identifying effective interventions and policies that influence the social determinants of mental health at national or scaled population level. We searched five databases (Cochrane Library, Global Health, MEDLINE, EMBASE and PsycINFO) between Jan 1st 2000 and July 23rd 2019 to identify systematic reviews of population-level interventions or policies addressing a recognised social determinant of mental health and collected mental health outcomes. There were no restrictions on country, sub-population or age. A narrative overview of results is provided. Quality assessment was conducted using Assessment of Multiple Systematic Reviews (AMSTAR 2). This study was registered on PROSPERO (CRD42019140198). Results We identified 20 reviews for inclusion. Most reviews were of low or critically low quality. Primary studies were mostly observational and from higher income settings. Higher quality evidence indicates more generous welfare benefits may reduce socioeconomic inequalities in mental health outcomes. Lower quality evidence suggests unemployment insurance, warm housing interventions, neighbourhood renewal, paid parental leave, gender equality policies, community-based parenting programmes, and less restrictive migration policies are associated with improved mental health outcomes. Low quality evidence suggests restriction of access to lethal means and multi-component suicide prevention programmes are associated with reduced suicide risk. Conclusion This umbrella review has identified a small and overall low-quality evidence base for population level interventions addressing the social determinants of mental health. There are significant gaps in the evidence base for key policy areas, which limit ability of national policymakers to understand how to effectively improve population mental health.

We use rich data on a cohort of English adolescents to analyse the long-term effects of experiencing bullying victimisation in junior high school. The data contain self-reports of five types of bullying and their frequency, for three waves of the data, when the pupils were aged 13 to 16 years. Using a variety of estimation strategies - least squares, matching, inverse probability weighting, and instrumental variables - we assess the effects of bullying victimisation on short- and long-term outcomes, including educational achievements, earnings, and mental ill-health at age 25 years. We handle potential measurement error in the child self-reports of bullying type and frequency by instrumenting with corresponding parental cross-reports. Using a detailed longitudinal survey linked to administrative data, we control for many of the determinants of bullying victimisation and child outcomes identified in previous literature, paired with comprehensive sensitivity analyses to assess the potential role of unobserved variables. The pattern of results strongly suggests that there are important long run effects on victims - stronger than correlation analysis would otherwise suggest. In particular, we find that both type of bullying and its intensity matters for long run outcomes.

Governments often aim to influence the amount and sectoral allocation of private investments through explicit or implicit subsidies. The rules used to select projects to benefit from subsidies may vary, depending on the policy objective. This paper develops a general framework to allocate subsidies to private investments in the presence of jobs-linked externalities (JLEs). JLEs emerge when wages exceed the opportunity cost of labor (labor externalities), or when there are social gains from creating better jobs for some classes of worker, such as women or youth (social externalities). Like all externalities, JLEs create a gap between private and social rates of return. Investments can be socially profitable (once the corresponding JLEs are internalized) but the private returns may be too low for the firm to go ahead. JLEs help to explain why many developing countries see insufficient investment in projects that would reallocate labor towards better jobs. The concept of JLEs is well established in economic literature, but there is a need for better operational approaches to address them. Like other externalities, JLEs can be corrected using a variety of possible subsidies (such as: grants, subsidized infrastructure, credit, training, technical assistance and tax exemptions). But doing this efficiently and at scale this requires mechanisms to (a) estimate the value of the externality and (b) discover the amount of subsidy needed to trigger the private investment. This paper shows that the optimal way to allocate subsidies to offset JLEs is through a competitive bidding process which selects projects based on the estimated amount of JLEs per dollar of subsidy. The bidding process provides an incentive to investors to reveal the subsidy needed for a project to become privately viable. We show that the proposed approach maximizes the jobs impacts of a given amount of fiscal resources that has been allotted to support better jobs outcomes

The Lancet Commission1 on global mental health and sustainable development highlighted the need to make mental health an integral part of global development. Treatment interventions are not enough to reduce the population-level burden of mental disorders, suggesting a public health approach to tackling the social determinants of mental health.1

Estimates of the graduate earnings premium typically do not allow for the effect of non-cognitive skills. Since such skills are unobservable in most datasets there is a concern that existing estimates of the graduate premium are contaminated by selection on such unobservables. We use data on a young cohort of individuals that allows us to control for the effects of non-cognitive skills.We find that the inclusion of non-cognitive skills, themselves jointly significantly positive reduces the estimated returns by an insignificant 1-2 percentage points from an average of 10-12%. Our second contribution is motivated by the greater reliance on administrative datasets in recent research that has focused on annual earnings rather than hourly wages and our results show that the graduate earnings differential is significantly greater than the wage differential.Since we use estimation methods that are NOT robust to selection on unobservables, we adopt Oster (2016) tests to show that it would take an implausible degree of selection on unobservables to drive our estimated wage and earings returns to zero, and that a plausible lower bound to returns is around one-quarter to one-third below the OLS returns. We further find heterogeneous returns by broad major group and elite university, and we find large degree class differentials.