Consensus Statement on the Role of the Family in the Physical Activity, Sedentary, and Sleep Behaviours of Children and Youth (0–17 years) and present, explain, substantiate, and discuss the final Consensus Statement.Children and youth who meet the physical activity, sedentary, and sleep behaviour recommendations in the Canadian 24-Hour Movement Guidelines are more likely to have desirable physical and psychosocial health outcomes. Yet, few children and youth actually meet the recommendations. The family is a key source of influence that can affect lifestyle behaviours. The purpose of this paper is to describe the process used to develop the Consensus Statement included the establishment of a multidisciplinary Expert Panel, completion of six reviews , custom data analyses of Statistics Canada’s Canadian Health Measures Survey, integration of related research identified by Expert Panel members, a stakeholder consultation, establishment of consensus, and the development of a media, public relations, communications and launch plan.The development of the Consensus Statement: Families can support children and youth in achieving healthy physical activity, sedentary and sleep behaviours by encouraging, facilitating, modelling, setting expectations and engaging in healthy movement behaviours with them. Other sources of influence are important  and can support families in this pursuit.Evidence from the literature reviews provided substantial support for the importance of family on children’s movement behaviours and highlighted the importance of inclusion of the entire family system as a source of influence and promotion of healthy child and youth movement behaviours. The Expert Panel incorporated the collective evidence from all reviews, the custom analyses, other related research identified, and stakeholder survey feedback, to develop a conceptual model and arrive at the Consensus Statement serves as a comprehensive, credible, and current synopsis of related evidence, recommendations, and resources for multiple stakeholders.Family is important for the support and promotion of healthy movement behaviours of children and youth. This  The Canadian 24-Hour Movement Guidelines were recently developed to provide public health guidelines integrating recommendations for physical activity, sedentary, and sleep behaviours for the pediatric population ranging from 0 to 4 years and 5 to 17 years –12. FurtBecause of the unequivocal holistic health benefits of healthy movement behaviours during childhood and adolescence, several authoritative groups around the world have released, endorsed or promoted evidence-based movement guidelines and recommendations to inform the public , 18–31. Many studies have shown that health benefits accumulate with each additional movement guideline met  , 32–37. The promotion of increased physical activity, decreased sedentary behaviour, and good sleep hygiene  can occur in multiple settings, such as in childcare , at schoConsensus Statement on the Role of the Family in the Physical Activity, Sedentary, and Sleep Behaviours of Children and Youth (0–17 years) to consolidate related evidence, highlight key facts, and provide guidance to families and those who support families on how to promote regular healthy movement behaviours of children and youth. The process and this manuscript were modelled after similar initatives that proved to be successful and well-received by the academic community  at home, childcare centres, schools and in communities, coupled with the new paradigm of integrated movement behaviours , 2, the  Youth 0–7 years to Scopus –69). TheActive Outdoor Play Position Statement in 2015  and 12–17 years) and sex. Similar analyses were also obtained for self-reported sleep duration, screen-time and physical activity domains ; however, adult and youth results are from cycles 4–5 combined only, and children and preschoolers results are from cycles 2, 3, 4, and 5 combined. Screen-time results included cycles 2, 3, 4 only due to a response option change in cycle 5 that makes it non-comparable to previous cycles. The CHMS also samples same-family parent-child dyads in approximately one fifth of the sample in each cycle. Recently, findings from the dyad file comparing parent-child physical activity, screen-time and fitness were also gathered.To better understand the relationships between family structure and child movement behaviours in Canada, custom analyses from Statistics Canada’s CHMS  were reqConsensus Statement and related manuscript, and report back to the multi-disciplinary Expert Panel. Expert Panel members were selected based on their research, practice, and/or professional experience related to the 24-Hour Movement Guidelines [Consensus Statement relates to the Report Card; present background efforts and research; brainstorm content/focus; and discuss the form, format, timelines and logistics of the Consensus Statement development. The Expert Panel was also invited to provide suggestions for additional panel members to fill any knowledge or expertise gaps. Four additional members were invited and all accepted invitations to be involved in the subsequent meeting and related project tasks.A small Steering Committee with four representatives  from the larger Expert Panel was formed to organize the work plan, complete the reviews, draft the idelines , 2 and/oConsensus Statement was created by the Expert Panel and finalized after the meeting through an iterative process to achieve consensus.The group met for a follow-up meeting in January 23–24, 2020 in Toronto, Canada, where results of the reviews and custom analyses were presented, other research evidence was discussed, a glossary and a conceptual model were developed, initial communication and dissemination strategies were planned, and organization for a stakeholder consultation was initiated. In addition, a first draft of the Consensus Statement. The survey was designed to seek assessments of the clarity and level of support for the various components of the Consensus Statement  separately. A copy of the survey is provided as Additional File Consensus Statement. The Consensus Statement was revised accordingly. Finally, the revised Consensus Statement was circulated to the entire Expert Panel for final comment, revisions, and sign-off. The final Consensus Statement was translated into French and both the English and French versions went through a creative design process by ParticipACTION for inclusion in the 2020 ParticipACTION Report Card. A summary overview of the timelines and key components of the Consensus Statement is provided in Fig. An online survey was developed and administered to solicit assessments and comments from stakeholders on the draft n = 4) or no response received (n = 4). One international delegate declined and the other did not respond. At the first Consensus Panel meeting four additional candidates were identified and invited to join. Invitations were sent and all four accepted. The final Expert Panel composition included 17 experts. Two research staff  provided significant support to the Expert Panel.Twenty-one candidates were initially invited to join the Expert Panel, including two international delegates, and information was provided on the commitement required. Fourteen of the invitations were accepted. Reasons for invitation decline were either too many concurrent commitments , sedentary behaviour  and sleep  are outlined in Table Inclusion and exclusion criteria for reviews #1–3 are summarized in Additional File Table SInclusion and exclusion criteria for reviews #4–6 are summarized in Additional File Table SThe results from the custom CHMS accelerometer analyses are presented below. In essence they show no significant differences in daily MVPA for boys or girls, of any age, based on number of siblings in the household. One exception is that for boys 12–17 years of age, having siblings had a positive association with physical activity. No differences in daily MVPA in 5-to-17 year-old children and youth according to a single- versus two-parent household structure; however, for 3-to-4 year-olds there is an effect whereby those living in households with two parents are more active than those living in households with one parent. There were no significant differences in the proportion of children aged 3 to 11 years meeting the daily MVPA recommendation of ≥60 min according to number of siblings in the household or single- versus two-parent household.Girls with no siblings or one sibling participated in more organized sports, lessons, and leagues compared to girls with two or more siblings;Boys with two or more siblings participated in more unstructured play outside of school compared to boys with one sibling or less;Girls in two-parent households participated in more organized sports, lessons, and leagues compared to girls in one-parent households;Girls and boys from two-parent households had less screen-time compared to single-parent households; and,Boys from two-parent households had more sleep compared to boys from single parent households.CHMS data on self- or parental-reported movement behaviours were also available for active transportation, recreational physical activity, occupational/household physical activity, screen-time and sleep duration by number of siblings in the household and by single- versus two-parent household. For children aged 3 to 4 years and for youth aged 12 to 17 years, there were no significant differences for any variables by number of siblings or parents. For children aged 5 to 11 years, the following significant differences were observed:In addition to the custom analyses described above, recently published findings from the CHMS examined parent and child sedentary behaviour and physical activity in early childhood . This stRecently published findings from the same family parent-child dyad file explored parent-child associations for physical activity and screen-time . These fFather-daughter pairs for cardiorespiratory fitness and muscular strength;Father-son pairs for muscular strength and flexibility; and.Mother-son pairs for muscular strength and flexibility.Custom dyad analyses using accelerometer data generally showed significant associations for MVPA and sedentary behaviour among mother-daughter dyads, and for MVPA among father-son dyads. Custom dyad analyses on measures of fitness also show significant associations between parents and children for cardiorespiratory fitness, muscular strength, and flexibility. Correlation analyses indicate that the relationship is stronger in:Collectively the results for the CHMS show that while number of siblings and single- versus two-parent households are not generally associated with 24-h movement behaviours, the behaviours  and characteritsics  of parents are associated with the behaviours and characteristics of their children. These findings align with those found in the various reviews described above where parental role modelling was consistently found to be an important correlate of children’s 24-h movement behaviours.n = 9), British Columbia (n = 18), Nunavut (n = 1), Ontario (n = 18), Prince Edward Island (n = 1), Quebec (n = 4), Saskatchewan (n = 1), and outside of Canada (n = 18).Sixty-seven stakeholders responded to the survey in the 4 days it was live. The sample consisted of a wide mix of sectors, yet a particularly large concentration of researchers . Further, stakeholders were from Alberta  important to their work, while only one stakeholder reported that it would not be important.Overall, stakeholders agreed with the n = 6) or confusing (n = 3). Changes were made to address these concerns. Second, there were several small suggestions about the conceptual model, and these were also incorporated in revisions. Third, four respondents commented that there was too much responsibility placed on the family, however this was before they reached the portion of the survey that dealt with the other sources of influence on the family . Nevertheless, additional clarification was added to improve clarity that although the Consensus Statement is focussed on the role of the family, the Statement also speaks to the importance of those who influence and can support families. Finally, two respondents suggested that a review be completed to ensure inclusive language, particularly with respect to children with a disability. This was also completed and revisions made accordingly.The survey respondents were engaged and provided many comments and suggestions. Most comments were minor editorial suggestions (which were made) or compliments. As noted above, the level of agreement was very high. Nevertheless, a few clusters of suggestions emerged, albeit from a small minority of respondents. First, there was some concern about the title – that it was unclear . The Consensus Statement concludes with key support resources, acknowledgements and references. It was designed to be a foundation of credible evidence from which programs, strategies, campaigns, policies and practices can be initiated and supported. The Consensus Statement as a knowledge product within the 2020 ParticipACTION Report Card on Physical Activity for Children and Youth [Consensus Statement can be found in Fig. https://participaction.com/consensus-statement). The Consensus Statement is also available in French at https://www.participaction.com/fr-ca/ressources/bulletin-de-participaction.After meeting to discuss the findings of the six reviews and the custom analyses, performing multiple rounds of reviews and revisions, and incorporation of feedback through the stakeholder survey, the Expert Panel reached consensus on the final nd Youth  was releConsensus Statement, a public relations and dissemination plan was developed and led by ParticipACTION. The release of the Consensus Statement benefited greatly from the proactive distribution, public relations and media strategy prepared to maximize and optimize the reach and impact of the release of the ParticipACTION Report Card. Through the Report Card, the Consensus Statement reached relevant stakeholders  across Canada. The general public  were reached directly through public-facing communications and social channels and indirectly through the media.To maximize the impact of the Consensus Statement, it was further shared by the networks of the Expert Panel members and their affiliated organizations. Specific findings were shared via ParticipACTION’s and other partnering individuals’/organizations’ social media channels . Press releases and communications with partnering organizations’ networks also took place on the day of release. An evaluation of the Consensus Statement release will occur as part of the larger, more comprehensive Report Card evaluation plan, including tracking of distribution, media impressions, hits and quality, website traffic and site visits, social media reach, and engagement among users. Surveys with Report Card users and debrief meetings with ParticipACTION’s strategic partners and Expert Panel members will provide further important insights.To ensure targeted reach to the specific audiences highlighted in the Consensus Statement on the Role of the Family in the Physical Activity, Sedentary, and Sleep Behaviours of Children and Youth to consolidate related evidence, highlight key considerations, and provide recommendations to families and other related networks on how to support regular healthy movement behaviours as outlined by the Canadian 24-Hour Movement Guidelines for Children and Youth [Consensus Statement  and family expectations (rules) were important for limiting children and youth’s sedentary behaviour and screen-time;healthy expectations such as setting bedtime routines and having device-free bedrooms and good family functioning were important for helping children and youth acquire sufficient sleep; and,the entire family system is an important source of influence and subsequent promotion of healthy child and youth behaviours.The Consensus Statement and add visual representation of the findings from our process, the Expert Panel developed a conceptual diagram that highlights how we situate family influence on child and youth movement behaviours  which examined whether interventions with a parent/other adult caregiver component resulted in children being more physically active, reported little to no impact on children’s activity levels [Despite existing adaptations of Family Systems Theory for child and youth health behaviour in the form of schematics, only two trials , 216 focWhile parental practices in relation to child and youth movement behaviours has been linked to subsequent child and youth behaviour, current research highlights the paucity in our understanding of parental practices related to sleep and restriction of sedentary behaviour. More research on the antecedents of parental practices is needed.Parental practices and support of all movement behaviours would be better understood with a greater focus on social  and environmental  correlates of support in conjunction with individual factors. Such evidence is required.Almost all of the current evidence-base on family support of child movement behaviours is focused on parents, and much of this is exclusive to mothers. Family functioning , structural arrangement supports  and overall family stakeholders  would assist in understanding the relative contributions of family influence.Research of family-based interventions for physical activity has improved over the last decade, yet family interventions on child and youth sleep and sedentary behaviour are limited. Primary research focussed on interventions to improve sedentary behaviours and sleep are still required in order to generate evidence-based recommendations.Interventions targeting a single movement behaviour are helpful, but we also recommend an examination of overflow effects on other non-targeted movement behaviours .Family intervention comparisons between integrated 24-h healthy movement behaviour approaches compared to isolated individual movement behaviour approaches will be a helpful future research direction to determine the best practice of  behaviour change.Determining the best knowledge translation and mobilization techniques to increase stakeholder’s awareness, knowledge, understanding, and implementation of recommended amounts of physical activity, sedentary behaviour, screen-time and sleep is needed.While the process we undertook to develop the y levels . The mosConsensus Statement was searched systematically and rigorously. The triangulation of evidence from multiple sources reinforced our confidence in the final Consensus Statement. Nevertheless, there are limitations to any large consensus building approach to develop similar public-facing documents. From this experience and others [This initiative was undertaken by a large interdisciplinary team of researchers, clinicians, policy experts, public health professionals, and front-line family service providers. Though we sought international representation for the Expert Panel, our final composition lacked an international perspective. The undertaking of multiple literature reviews and custom national data analyses combined with ongoing expert consultation, was a significant strength of this project. The findings of this work have the potential to inform future contributions to the child health literature, care, and practice. With the pragmatic use of literature searches and scoping reviews rather than systematic reviews being carried out, data quality, full synthesis of findings, and risk of bias were not always considered. This choice was acknowledged as a limitation by the group, but all evidence for the development of the d others –69, 76 wConsensus Statement on the Role of the Family in the Physical Activity, Sedentary, and Sleep Behaviours of Children and Youth. This Consensus Statement is intended to facilitate a positive focus on the importance of key practices, policies, and societal actions to promote healthy child and youth growth and development through the integrated 24-h movement behaviours. The release of the Consensus Statement will benefit greatly from the proactive distribution, public relations and media strategy prepared to maximize the reach and impact of the release of the ParticipACTION Report Card. Through this, it is anticipated that the Consensus Statement will reach relevant government and non-government organizations whose work impacts child and youth movement behaviours across Canada and globally. Parents, educators, practitioners, service providers, lawmakers, and government will also be reached through public-facing communications channels  of ParticipACTION and collaborating organizations.In summary, there is broad triangulation support from the published literature, current nationally representative data, the Expert Panel, and the stakeholders consulted to support the Additional file 1 Survey (PDF file of on-line survey). Full survey questions used to solicit assessments and comments from stakeholders on the draft Consensus Statement.Additional file 2. Table S1 (docx). Inclusion and exclusion criteria for systematic literature searches on family and the physical activity (review #1), sedentary (review #2), and sleep (review #3) behaviours of children and youth.Additional file 3. Review #1 (docx.). Search Process for Family and Physical Activity Literature Review (review #1). Themes from the physical activity literature review (review #1). References for the papers included in the family and physical activity review (review #1), organized by theme.Additional file 4. Review #2 (docx.). Search Process for Family and Sedentary Behaviour Literature Review (review #2). Themes from the sedentary behaviour literature review (review #2). References for the papers included in the family and sedentary behaviour review (review #2), organized by theme.Additional file 5. Review #3 (docx.). Search Process for Family and Sleep Behaviour Literature Review (review #3). Themes from the sleep literature review (review #3). References for the papers included in the family and sleep review (review #3), organized by theme.Additional file 6. Table S2 (doc.). Inclusion and exclusion criteria for systematic literature searches on family systems theory (review #4), parental correlates (review #5), and family interventions (review #6) for movement behaviours of children and youth.Additional file 7. Review #4 (docx.). Search Process for the Family Systems in the Context of Child Health Behaviour Change and Family-Based Interventions Scoping Review (review #4). References extracted from the Family Systems in the Context of Child Health Behaviour Change Scoping Review (review #4).Additional file 8. Review #5 (docx.). Search Process for the Correlates of Parental Support of Child and Youth Physical Activity, Sedentary Behaviour, and Sleep Systematic Review (review #5). References Extracted from the Correlates of Parental Support of Child and Youth Physical Activity, Sedentary Behaviour, and Sleep Systematic Review (review #5).Additional file 9:. Figure S1 (doc.). Search process of the Review of Reviews on Interventions Involving the Family to Change Child and Youth Physical Activity, Sedentary Behaviour, and Sleep (review #6).


The purpose of the present study was to examine fruit and vegetable consumption according to gender, educational attainment and regional affiliation in Europe.Cross-sectional study.21 European countries.th round of the European Social Survey.37 672 adults participating in the 7Fruit and vegetable consumption was measured using two single frequency questions. Responses were dichotomized into low (<once a day) and high (≥once a day) consumption. The association between consumption of fruit and vegetables and gender, educational level, regional affiliation was examined using logistic regression analyses.Overall, females showed increased odds of consuming fruit  and vegetable ) compared to males and high educated participants showed increased odds of consuming fruit ) and vegetables ) compared to low educated participants. Our results also showed that participants living in Eastern Europe had the lowest odds of consuming fruit and vegetables, whereas participants from Southern- and Northern Europe had the highest odds of consuming fruit and vegetables, respectively. Results from interaction analyses confirmed the positive association between fruit and vegetable consumption and educational level, although for some European regions, decreased odds of fruit and vegetables was observed among medium educated participants compared to those with low education.Overall, the present study showed that being female and having a high education were associated with increased consumption of fruit and vegetables. However, the direction and strength of these relationships depends on regional affiliations. Studies have confirmed that low consumption of fruit, vegetables and fruit and vegetables combined, is associated with increased risk of cardiovascular disease, type 2 diabetes, cancer, and all-cause mortality.,2,3 In aOrganized health promotion and disease prevention efforts in most European countries have focused specifically on initiatives to increase the consumption of fruit and vegetables among different groups.,6 The weEducational attainment has been identified as one of the most important predictors of fruit and vegetable consumption and has also been positively associated with diet quality, diversity and higher odds to comply with national recommendations.,8,9 StudAlthough most European studies have reported a graded relationship between educational attainment and fruit and vegetable consumption, this is not a consistent finding. ,13–16 SoThe health module of the 7th round of the European Social Survey provides us with a unique opportunity to overcome these limitations with reliable and comparable estimates. Thus, the aim of the present study was to examine how the consumption of fruit and vegetables varies according to gender, educational attainment and regional affiliation in a large representative sample of the European adult population.(REC) was established in 2015, and the present study was approved in accordance with the ESS ERIC Statutes (Article 23.3). The ESS ERIC subscribes to the Declaration on Professional Ethics of the International Statistical Institute, which can be downloaded from https://www.isi-web.org/index.php/activities/professional-ethics/isi-declaration.The data was collected in 2014 as part of round 7 of the European Social Survey (ESS), in face-to-face interviews, using a standardized procedure, and designed to be representative of all persons aged 15 and over, resident within private households in each country. Written informed consent was obtained from all participants prior to data collection. The ESS ERIC Research Ethics Committee The total sample included 37 762 respondents. More information regarding the European Social Survey has been previously published elsewhere. The follThe data utilized for analyses in the present study was based on a self-report questionnaire which focused on attitudes, beliefs and behaviour patterns. Fruit consumption was measured by asking respondents ‘How often do you eat fruit, excluding drinking juice? Frozen fruit should be included’. Vegetable consumption was measured by asking ‘How often do you eat vegetables or salad, excluding potatoes? Frozen vegetables should be included’. Response categories for both fruit and vegetable consumption were: ‘1. Three times or more a day; 2. Twice a day; 3. Once a day; 4. Less than once a day but at least 4 times a week; 5. Less than 4 times a week but at least once a week; 6. Less than once a week; 7. Never. A consumption of once a day or more was acknowledged as an acceptable frequency of consuming these food items. Thus, consumption of both fruit and vegetables were further dichotomized into once a day or more  or less than once a day . The survey did not provide data on quantity and variety of fruit and vegetable consumption.The variable capturing age was coded into 5-year increments, from 15 upwards and capped at 79. Gender was coded as a dummy variable . Educational attainment was coded into three categories where no education, primary education and lower secondary education was coded as ‘low education’, upper secondary education was coded as ‘medium education’ and tertiary education was coded as ‘high education’. Dummy variables were also created to capture regional affiliation. The countries coded as Northern European include Denmark, Estonia, Finland, the UK, Ireland, Lithuania, Norway and Sweden. The countries coded as Western European include Austria, Belgium, Switzerland, Germany, France and the Netherlands. Finally, countries coded as Eastern European include Czech Republic, Hungary and Poland, while Portugal, Slovenia, Spain and Italy were coded as South Europe.Statistical analyses were carried out using Stata 16. We have presented descriptive statistics, including age, gender, education and fruit and vegetable consumption for each of the 21 European countries as well as mean values for the pooled sample.Further, fruit and vegetable consumption were analysed separately, using logistic regression analyses to estimate odds ratios for high frequency of fruit and vegetable consumption according to gender, education and regional affiliation. The ESS post-stratification weight was applied in all analyses. In the first part of the analyses, we examined odds ratios for high frequency of fruit and vegetable consumption according to gender, education and regional affiliation. Based on the results from these analyses, we further examined how interactions between regional affiliation and education affect frequency of fruit and vegetable consumption among men and women, respectively. Thus, we used regression analyses stratified by gender to examine how FV consumption varied among participants from different European regions according to educational level using low educated Eastern European males or females as reference groups, respectively. All regression models were adjusted for age and the likelihood ratio test confirmed that the interactions between region and education were statistically significant contributors to the models focusing on both fruit and vegetable consumption (p<0.001 for both). We also conducted a chow test which confirmed that education and region have a significantly different impact on consumption frequency among women compared to men, related to both fruit and vegetables (p<0.001 for both).Descriptive results are presented in Regression analyses for the pooled sample adjusted for age  showed iAnalyses presented in Compared to low educated males from Eastern Europe (ref), the results showed increased odds of consuming fruit among low and high educated males living in Northern Europe  and OR 2.26 , respectively), Western Europe  and OR 1.89 , respectively) and Southern Europe  and OR 2.91 , respectively).Likewise, increased odds of consuming fruit were observed among low and high educated females from Northern Europe  and OR 3.52 , respectively), Western Europe  and OR 2.89 , respectively) and Southern Europe  and OR 3.97 ) compared to low educated females from Eastern Europe (ref).Among Eastern European participants, medium educated males showed decreased odds of vegetable consumption compared to low educated males. Furthermore, the results showed increased odds of consuming vegetables among low and high educated males from Northern Europe  and OR 3.53 , respectively), Western Europe  and OR 2.55 , respectively) and Southern Europe  and OR 4.53 , respectively), compared to low educated Eastern European males (ref).For females, similar results showed increased odds of consuming vegetables among low and high educated participants from Northern Europe  and OR 6.41 , respectively), Western Europe  and OR 6.53 , respectively) and Southern Europe  and OR 4.53 , respectively), compared to low educated females in Eastern Europe (ref).Based on the total study sample, the results showed a gender and education gradient in which being female and having high education was associated with increased consumption of fruit and vegetables. Overall, our results also showed that participants living in Eastern Europe had the lowest odds of consuming fruit and vegetables, whereas participants from Southern- and Northern European countries had the highest odds consuming of fruit and vegetables, respectively.Although few previously published studies have compared data from many different European countries, variations in the patterns of fruit and vegetable consumption between countries and regions have been identified.,13–16 SiIn our study, interaction analyses examining the association between regional affiliation and consumption of fruit and vegetables also revealed interesting nuances in the results; high educated Eastern European females, but not males showed significantly increased odds of consuming fruit and vegetables compared with low educated participants from this region. Medium educated males, however, showed decreased odds of consuming vegetables compared to low educated males from Eastern Europe. Furthermore, some results also indicate decreased odds of fruit and vegetables among medium educated participants compared to those with low education.These results may partly be explained by findings from a few previously published studies, which showed that in regions characterized by high availability, high affordability and high consumption of fruit and vegetables, lower social classes tend to have a higher consumption of fruit and vegetables than higher social classes.,18 Roos Compared with previously published studies focusing on socio-demographic differences in fruit and vegetable consumption, the present study has improved the comparability by using standardized data collection methods, including nationally representative data from 21 countries in Europe. When interpreting the results from the present study, several other methodological aspects must be taken into consideration. One of the most important limitation was that only data concerning frequency of fruit and vegetable consumption, rather than portion sizes, were available. Due to limited data, it was not possible to calculate whether the respondents fulfilled the WHO criteria of eating 5 portions of fruit and vegetables per day. Furthermore, the questions used to identify frequency of vegetable consumption did not specify that processed vegetables should be reported as well as consumption of fresh vegetables. As vegetables traditionally are consumed in cooked form in several Eastern European countries, the consumption of vegetables among Eastern European participants may have been underestimated. It should also be noticed that generally, frequency questionnaires often tend to over-estimate the consumption of fruit and vegetables regardless of regional affiliation. The presBeing female and having high educational level was positively associated with fruit and vegetable consumption in most European regions. However, the results showed some variations in consumption according to educational level and regional affiliation. Knowledge about inequalities in fruit and vegetable consumption according to gender, educational attainment and regional affiliation should inform the development of public health policies and practices across Europe.


Effective risk communication about the outbreak of a newly emerging infectious disease in the early stage is critical for managing public anxiety and promoting behavioral compliance. China has experienced the unprecedented epidemic of the coronavirus disease (COVID-19) in an era when social media has fundamentally transformed information production and consumption patterns.This study examined public engagement and government responsiveness in the communications about COVID-19 during the early epidemic stage based on an analysis of data from Sina Weibo, a major social media platform in China.Weibo data relevant to COVID-19 from December 1, 2019, to January 31, 2020, were retrieved. Engagement data  of posts from government agency accounts were extracted to evaluate public engagement with government posts online. Content analyses were conducted for a random subset of 644 posts from personal accounts of individuals, and 273 posts from 10 relatively more active government agency accounts and the National Health Commission of China to identify major thematic contents in online discussions. Latent class analysis further explored main content patterns, and chi-square for trend examined how proportions of main content patterns changed by time within the study time frame.21=13.3, P<.001), attribute blame to other individuals or government , and express worry about the epidemic , while government posts were more likely to share instrumental support  and praise people or organizations . As the epidemic evolved, sharing situation updates  and policies, guidelines, and official actions  became less frequent in personal posts but remained stable or increased significantly in government posts. Moreover, as the epidemic evolved, showing empathy and attributing blame  became more frequent in personal posts, corresponding to a slight increase in sharing instrumental support, praising, and empathizing in government posts .The public response to COVID-19 seemed to follow the spread of the disease and government actions but was earlier for Weibo than the government. Online users generally had low engagement with posts relevant to COVID-19 from government agency accounts. The common content patterns identified in personal and government posts included sharing epidemic situations; general knowledge of the new disease; and policies, guidelines, and official actions. However, personal posts were more likely to show empathy to affected people (χThe government should closely monitor social media data to improve the timing of communications about an epidemic. As the epidemic evolves, merely sharing situation updates and policies may be insufficient to capture public interest in the messages. The government may adopt a more empathic communication style as more people are affected by the disease to address public concerns. On December 31, 2019, a cluster of pneumonia cases of unknown etiology were first reported in Wuhan, the capital city of Hubei Province, China , but latThe outbreak of a newly emerging respiratory infectious disease usually puts individuals at a high risk of infection and constitutes a highly uncertain situation that changes rapidly, threatening serious potential loss and prompting considerable psychological distress ,10. FeelThe high penetration of internet use and rapid development of information and communication technologies have made the internet an increasingly important health information source worldwide -23. ReadWith the proliferation of internet and social media used as health information sources, infodemiology (or infoveillance), the study (or surveillance) of “distribution and determinants of information,” in the internet or a population for the aim of guiding policy making and public health interventions  has beenThe outbreak of COVID-19 was an unprecedented epidemic that China experienced for the first time in this digital era. Based on this study’s literature review on important principles of effective outbreak communication and the knowledge gaps of current infodemiology or infoveillance studies examining outbreak communication using social media data, this study aimed to make use of the Weibo data about COVID-19 from December 2019 to January 2020 in China to answer the following research questions:How did the public respond to the outbreak of COVID-19 as cases of COVID-19 increased and increasingly stringent containment measures were implemented, and how quickly could the government respond to public discussions about COVID-19?To what extent could government messages about COVID-19 engage the general online users?What contents did the public discuss online, and how did these contents change as the epidemic evolved? To what extent could the government respond to the temporal change of public discussions online?Four keywords in Chinese characters were used to capture data relevant to COVID-19 from Weibo from December 1, 2019, to January 31, 2020: “Wuhan pneumonia,” “novel coronavirus,” “novel coronavirus pneumonia,” and “novel pneumonia.” Data were retrieved using the built-in Weibo searching function and were subsequently screened by the Python Web Crawler, a tool that has been demonstrated to be efficient in identifying the most relevant posts that contain the set keywords . A totalThis study evaluated how much government posts can engage online users in the communications about COVID-19 by calculating the engagement index using engagement data of the posts delivered by government agency accounts ,45. The There is currently no consensus about how to best sample social media data for content analysis , but ranAs a comparison with personal account posts and supplement for understanding government responsiveness in the communications about COVID-19, we also analyzed the contents of all posts from the first 5 government accounts of both the health and nonhealth sectors based on the rank of the engagement index and posts from the NHC in the same period. The first government post relevant to COVID-19 was posted on December 31, 2019. A total of 273 government posts were included for content analysis.A tentative coding scheme was first developed based on preliminary analysis of a random training subset of 100 posts using open coding by one author (QL) and iteratively refined through independent analysis of another 100 training posts by authors QL, JY, and MD, and discussion from the team. The coding scheme was then used by two authors (JY and MD) to analyze the 274 selected government posts and 644 selected individual posts for final content analysis, each analyzing half of these posts. Although the coding scheme was used, the coders were advised to be open to new codes during the analysis. After both coders finished their part, they mutually checked 10% of the posts from each other’s subset to ensure consistency in coding. Finally, one author (QL) double-checked a random subset of 10% of all posts for content analysis to ensure the accuracy and reliability of the coding. Any inconsistencies were solved by going back to relevant data and joint discussions among authors QL, JY, and MD to reach an agreement. Interrater reliability was assessed by calculating Cohen kappa, with a value of 0.6 or above indicating adequate reliability. The set of codes finally generated were then constant compared to develop thematic categories.A Pearson chi-square test was used to compare the overall percentages of each thematic category between personal account posts and government agency posts. Latent class analysis (LCA) was used to explore main patterns of post contents by type of account. To conduct the LCA, we first generated a binary-coded variable (1=the specific thematic category is present and 0=the specific thematic category is absent) for each thematic category coded for each post. These variables were then entered into Mplus 7.3 (Muthén and Muthén) for LCA. Major fit indices provided by Mplus including Akaike information criterion (AIC), Bayesian information criterion (BIC), sample size adjusted BIC (aBIC), and the entropy value were used to determine the optimal number of class for the post contents of both personal accounts and government agency accounts. A model with smaller values of AIC, BIC, and aBIC but with a higher entropy value is preferred, but we also consider the interpretability of the model and model parsimony . The LCAWe detected information prevalence in relation to the outbreak by plotting daily numbers of Weibo posts by type of accounts with daily numbers of newly confirmed cases of COVID-19 in Frequencies and proportions of thematic categories of post contents for personal and government accounts are shown in sharing knowledge or information, emotional exchange, and seeking information of which only the first 2 were identified in government posts. As is shown in sharing knowledge and information in both groups, the most common thematic categories were situation updates of COVID-19 followed by general knowledge about coronavirus pneumonia and advice on preventive measures. Government agency posts were more likely to share information about policies, guidelines, and official actions , and instrumental support , while personal account posts were more likely to share information on public responses to the epidemic . Personal account posts were more likely to be classified as emotional exchange  including showing empathy to affected people , attributing blame to people or organizations for malpractice during the epidemic , and expressing worry about the epidemic . The government posts more likely praised people or organizations . The main groups of people praised by both groups were health care workers, while the main people or organizations being blamed in personal account posts included other individuals  and the government . Regarding seeking information, the main information sought was updates about the epidemic situation.We noted 3 cyber-support behaviors from personal account posts: 22=15.9, P<.001), while the Hubei Red Cross Society of China were more likely to post contents about instrumental support  and showing empathy to affected people .Compared with post contents of government agencies from the health sector, we found that the four government agencies from the system of public security bureaus were more likely to share information about situation updates  but declined thereafter . Sharing general knowledge  and policies, guidelines, and official actions  declined each week, while showing empathy and blaming increased significantly in later weeks , and worry about the epidemic remained stable and low. For government agency account posts, sharing situation updates and prevention tips, and fighting against rumors remained stable; sharing general knowledge declined each week , while sharing policies, guidelines, and official actions , and providing instrumental and emotional empathy and praising people  increased significantly on the last 2 weeks of the study time frame.The temporal change of each content pattern by type of account are shown in 21=4.2, P=.04)We also specifically explored how providing reassurance, a main emotional content in government posts, changed as the epidemic evolved. We found that providing reassurance in government posts was more frequent in the first 3 weeks but declined in the last 2 weeks of the study time frame , commitments (comments per post per 1000 followers), and virality (shares per post per 1000 followers) may indicate low levels of interest, use, emotional arousal, or even credibility of the government information among the online audiences ,51. ThisThe content analysis suggests that the Chinese government agencies mainly used social media to “inform” the public about updates of the epidemic situation; knowledge of the coronavirus pneumonia; policies, guidelines, and government actions; and prevention tips, all being the key risk messages included in the official websites of health authorities for communicating about an epidemic . This suFirst, individual posts were sampled by randomly choosing equal numbers of posts per calendar day for content analysis rather than using the common probability-based random sampling, which would generate a large sample size due to the vast amount of social media data. However, there is currently no consensus about how to best sample social media data, and our sampling strategy was able to draw a random manageable sample using manual coding. Second, only posts of government agencies that were more actively engaged with the public in online communication about COVID-19 were included for content analysis. This means that the sample of government posts for content analysis may not be representative of all government posts. However, this sample was considered to have greater impact on online audience’s knowledge, perceptions, attitudes, and behaviors due to greater audience interest and attention to their messages. Third, our study did not evaluate the responses to and concerns over COVID-19 among nonnetizens, particularly those living in rural areas and older people in China , and theThe governments can closely monitor the social media discussions to identify public concerns to further improve government responsiveness in outbreak communication. To improve government responsiveness and public engagement, first, persons who have received training in risk communication can be designated for monitoring public concerns online, delivering timely messages, communicating about the uncertainty, and making efforts to address public concerns online. Second, the municipal health commission can communicate more locally relevant information to attract local followers’ interest and motivate their information sharing. Third, the provincial and national health commissions can organize direct dialogues with online audiences on social media  with trustworthy health care workers to capture audience’s attentions and interests, and facilitate the rapid spread of fact-related messages . AlthougThe public seemed to respond earlier to the outbreak of COVID-19 online than government agencies. TThe Chinese government agencies’ use of social media for outbreak communications remained limited to providing knowledge and information to the public. As the epidemic evolved, the public had declining interest in fact-related messages but became more empathic with the affected people and tended to attribute blame to other individuals or the government. The tendency of increasingly attributing blame to other individuals or the government may push the Chinese government to seek accountability and refine the compensation system for affected people. As more people are affected, the government may adopt a more empathic communication style to address public emotional response.


Whilst several systematic reviews conducted in Low- and Middle-Income Countries (LMICs) have revealed that coverage under social (SHI), national (NHI) and community-based (CBHI) health insurance has led to increased utilization of health care services, it remains unknown whether, and what aspects of, these shifts in financing result in improvements to mental health care utilization. The main aim of this review was to examine the impact of SHI, NHI and CBHI enrollment on mental health care utilization in LMICs.Systematic searches were performed in nine databases of peer-reviewed journal articles: Pubmed, Scopus, SciELO via Web of Science, Africa Wide, CINAHL, PsychInfo, Academic Search Premier, Health Source Nursing Academic and EconLit for studies published before October 2018. The quality of the studies was assessed using the Effective Public Health Practice Project quality assessment tool for quantitative studies. The systematic review was reported according to the PRISMA guidelines .Eighteen studies were included in the review. Despite some heterogeneity across countries, the results demonstrated that enrollment in SHI, CBHI and NHI schemes increased utilization of mental health care. This was consistent for the length of inpatient admissions, number of hospitalizations, outpatient use of rehabilitation services, having ever received treatment for diagnosed schizophrenia and depression, compliance with drug therapies and the prescriptions of more favorable medications and therapies, when compared to the uninsured. The majority of included studies did not describe the insurance schemes and their organizational details at length, with limited discussion of the links between these features and the outcomes. Given the complexity of mental health service utilization in these diverse contexts, it was difficult to draw overall judgements on whether the impact of insurance enrollment was positive or negative for mental health care outcomes.Studies that explore the impact of SHI, NHI and CBHI enrollment on mental health care utilization are limited both in number and scope. Despite the fact that many LMICs have been hailed for financing reforms towards universal health coverage, evidence on the positive impact of the reforms on mental health care utilization is only available for a small sub-set of these countries. In 2005, the World Health Assembly endorsed a resolution urging its member states to work towards sustainable health financing with a view to achieving universal health coverage (UHC) –3. UHC iHealth financing reforms include changes in the way that revenues for health are generated and collected, how they are pooled to spread risks, the means by which the provision and purchasing of services are determined and how providers should be paid , 6. WhilWhilst in practice, the definition of these systems are often blurred; NHI is generally understood as a mandatory contribution scheme, with pooling of resources at the national level and a single purchaser model for purchasing a package of services for all citizens, regardless of whether they have contributed –11. In talmost achieved universal coverage through health financing reforms. Countries include Cambodia, Chile, Colombia, Costa Rica, Estonia, the Kyrgyz Republic, Philippines, Sri Lanka, Thailand, Tunisia, and Vietnam [There has already been remarkable success among several LMICs in that these countries are considered to have  Vietnam , 15. Whi Vietnam , 15. As  Vietnam , 9.A key concern amongst many LMICs is the low priority afforded to mental health. Despite the prevailing successes in LMICs transitioning toward sustainable mandatory health financing systems, the burden of mental disorders is increasing globally, with 1.1 billion people affected by a mental or substance use disorder, worldwide causing 8% of all Disability-Adjusted-Life-Years (DALYs) and 18.5% of all Years Lived with Disability (YLD) , 17. AftA large multi-country survey supported by the WHO showed that 76–85% of people with severe mental disorders  in low-income countries had not received any treatment in the previous 12 months; whilst the treatment gap for minimally adequate treatment for major depression and anxiety exceeds 80%  among LMICs –20. TherIn light of the explicit inclusion of mental health within the SDG targets, recognizing its ongoing neglect health agenda, accumulating a body of evidence identifying the role of National Health Insurance mechanisms in increasing health care utilization, including for MNS disorders, will lend itself to the inclusion of mental health within the package of services being provided within countries aspiring towards UHC. Whilst several systematic reviews conducted in LMICs have revealed that coverage under social, national and community-based health insurance schemes has led to increased utilization of health care services, it remains unknown whether, and what aspects of, these shifts in financing result in improvements in mental health care utilization, thereby achieving the objectives of universalizing health care, inclusive of access to care for MNS disorders , 23, 24.We developed a protocol for this review according to the PRISMA guidelines  and in 2or 2017 definitions to allow for income changes over time; and (iv) were available in English. Studies were excluded if they were (i) qualitative descriptive studies, policy reviews, systematic reviews, opinion pieces, editorials, letters to the editor, book chapters, commentaries or conference abstracts; (ii) written in a non-English language, and; (iii) were conducted in a high-income country as at 1987 and 2017. Studies whose primary outcome was not mental health care utilization but provided a secondary analysis with comparisons of mental health care utilization by insurance status were also included. Studies that explored the impact of private health insurance on mental healthcare utilization were excluded, unless they were included as a comparison group. The present study defines MNS disorders as encompassing: Alcohol use disorders; Neurological disorders ; Illicit drug use disorders ; Eating disorders ; Mood disorders ; Psychotic disorders (Schizophrenia); Autism spectrum disorders ; Behavioural disorders ; and Developmental disorders .The inclusion and exclusion criteria are listed in Table A systematic search for peer-reviewed articles published until October 1st, 2018 was conducted between 05 and 09 October 2018. We searched nine databases of peer-reviewed journal articles: Pubmed, Scopus, SciELO via Web of Science, Africa Wide, CINAHL, PsychInfo, Academic Search Premier, Health Source Nursing Academic and EconLit. The search strategy included the use of a combination of free text, indexing terms, database-specific limits  and database-specific subject headings/vocabulary ). Multiple search terms for each of the following three concepts were developed: (1) social, national and community-based health insurance; (2) mental health care, and; (3) low- and middle-income countries  onto a predesigned Excel-based data extraction form. The purposely designed, pre-piloted, spreadsheet of tables included: study source, design and participant characteristics, type and characteristics of the insurance mechanisms under examination including (where specified) revenue generation, pooling and purchasing arrangements as well as characteristics of the benefit package; the results for our primary outcome , other relevant secondary results, and the results of the study’s quality assessment. Quality of these studies was assessed by the Effective Public Health Practice Project (EPHPP) quality assessment tool for quantitative studies . QualityGiven the heterogeneity of the study designs, the insurance mechanisms being examined, and the outcome measures of mental health care utilization reported in the identified studies, a meta-analysis was not conducted. Instead, a qualitative synthesis of findings is presented, which compares, evaluates and summarizes findings narratively in relation to the review questions. Descriptive statistics were calculated using STATA 13.Before narratively synthesizing the impact of SHI, NHI or CBHI on mental health care utilization, given the lack of specific details regarding the particular financing mechanisms under examination in the included studies and to give context to the results, we have outlined the characteristics of the SHI, NHI and CBHI schemes that have been examined within the included papers, including their population coverage, revenue generation and pooling arrangements, benefits packages and provider payment mechanisms. These are provided as an Additional File based on a review of secondary sources  and in the second, findings were mentioned in the discussion with no empirical data outlined in the results (n = 1); corresponding authors were contacted for access to these data and no responses were obtained. In total 18 studies were included in the final review. Reviewer agreement on selection of publications for final review was 94.2% (kappa = 0.81).A total of 2857 articles were identified from databases, of which 2426 abstracts were screened for eligibility Fig. . In totan = 16, 89%), including twelve in China [The majority of articles were published in Asia  of the articles included mental health care utilization for schizophrenia [n = 3) included mental health care utilization for epilepsy [n = 2) included mental health care utilization for depressive and anxiety disorders [With respect to the MNS disorders for which utilization was examined, 33%  [The majority of studies included in this review adopted a cross-sectional design (n = 10) , 44, 45;n = 10) , 39, onen = 10)  and fiven = 10) , 38, 43 n = 10) , 41, 43.n = 10) , 39, 42;n = 10) , 44, 45.Four of the included studies explored the impact of health insurance on outpatient mental health care utilization, exclusively , 41, 44;long-stay indicating that their inpatient admission lasted longer than 180 days [Our primary outcome of interest, mental health care utilization, was operationalized in a number of different ways across the included studies. The length of inpatient admissions was used as a measure of utilization in four of the included studies; three of which defined length of stay in terms of duration of inpatient admissions , 31, 33 180 days . Outpati180 days ; and the180 days . The abs180 days . Self-re180 days .Prescription of and compliance with medication was included as an outcome for eight studies included in this review. Compliance with medications was used as a measure of utilization in two of the included studies; one study reported on the rates of compliance with antiepileptic drug (AED) regimens over the past year defined as the number of patients that took their prescribed AEDs on time, without fail, without manipulating dosage, 100% of the time  whilst tnew AEDs (lamotrigine 100 mg), which are considered to render better control of seizures with fewer side effects [Studies comparing more- or less-favorable medications for MNS disorders included one study which examined the utilization of  effects . A secon effects ; here th effects  whilst a effects . A fifth effects .Finally, two studies examined the impact of insurance enrollment on the likelihood of and proportion receiving electroconvulsive therapy (ECT) in inpatient settings where the authors note that ECT is known for a high risk of cognitive impairment , 37.Of the included studies examining the impact of insurance enrollment on the length or frequency of inpatient admissions , 38, 40;The length of inpatient admission among the uninsured urban population of China who were hospitalized between 2002 and 2004 for schizophrenia, bipolar affective disorder, vascular dementia, mental and behavioural disorders due to alcohol, manic episodes or depressive episodes was 60 days, compared with 120·7 days and 98·9 days for those enrollled in UE-BMI or UR-BMI schemes and those enrolled in the GIS, respectively . SimilarFeng et al. (2012) examined the length of inpatient admissions among the population of Changsha, China diagnosed with schizophrenia who made use of inpatient care in 2010 . For thoAmong patients with any psychiatric diagnoses discharged from Guangdong Psychiatric Hospital between 2010 and 2013, those enrolled in the NCMS scheme had on average the fewest number of inpatient admissions (1·7) when compared to those enrolled in the UE-BMI or UR-BMI schemes  and those enrolled in the GIS scheme . As secondary outcomes, the authors report that those enrolled in the GIS, UE-BMI or UR-BMI schemes were 1·6 and 2 times more likely to be hospitalized a second time; 3·1 and 3 times more likely to have a third hospitalization, and; 5·3 and 4·8 times more likely have more than 3 hospitalizations, when compared to those enrolled in the NCMS scheme.long-stay) among those enrolled in the NHI scheme and those enrolled in either the Medical Care Aid 1 or Medical Care Aid 2 schemes [In South Korea, Chung et al. (2013) compared the proportion of patients who received inpatient care for schizophrenia between 2005 and 2006 that were hospitalized for longer than 180 days  in China was the only identified study that examined the influence of insurance enrollment on the use of outpatient rehabilitation services  . The autinsured, even if some private services and out-of-pocket expenses exist in parallel); 82.2% and 86.7% of those diagnosed with depression and schizophrenia, respectively, reported ever having received treatment [uninsured), 37.1% and 53.3% of those diagnosed with depression and schizophrenia, respectively, reported ever having received treatment [A study exploring the influence of insurance enrollment across 48 low- and middle income countries conducted by El-Sayed et al. (2015) examined the self-report of having ever received treatment for depression and schizophrenia among those diagnosed . Among creatment . Among creatment .When disaggregated by biological sex, in adjusted models among men, the uninsured had a lower likelihood of treatment for depression  whilst amongst women, adjusted models demonstrated that the uninsured were significantly less likely to receive treatment for schizophrenia  . FurtherAsawavichienjinda et al. (2003) compared the rates of compliance with antiepileptic drug (AED) regiments over the past year among those enrolled in the Thai Health Card Scheme, a CBHI mechanism, versus the uninsured . The stuWith regards to the prescription of medications, Ding et al. (2018) examined the proportion of individuals with active epilepsy in Zhejiang, China, that did not receive any anti-epileptic medication  between 2013 and 2014 . The stunew AEDs, which are considered to render better control of seizures with fewer side effects [Another study comparing more- or less-favorable medications was conducted by Hirunrassamee et al. (2009) which explored the influence of enrollment in Thailand’s Universal Health Coverage scheme , Social Security Scheme (SSS) and the Civil Service Medical Benefits Scheme (CSMBS) – the latter two mechanisms being considered social health insurance mechanisms . Between effects  was high effects . Among t effects . As a se effects .The utilization of tricyclic antidepressants (TCAs) among elderly Koreans in primary care settings by enrollment in Korea’s National Health Insurance scheme was examined by Hwang et al. 2018, 41). The authors compared the proportion of antidepressants prescribed that were TCAs among those enrolled in the NHI scheme, those enrolled as Medical Care Aid beneficiaries (i.e. lacking economic capacity to contribute to NHI) and those enrolled in the Veterans Health Insurance scheme [. The autYu-tao et al. (2007) examined the number of outpatients diagnosed with schizophrenia that were prescribed Anticholinergic Medication (ACM), known for a variety of side effects including the impairment of cognitive capacity, among those enrolled in either UE-BMI, UR-BMI or GHI with the uninsured in Hong Kong and Beijing between 2005 and 2006 . Among tWith regards to the receipt of specific inpatient therapies, both studies included examined the impact of insurance enrollment on the likelihood of and proportion receiving electroconvulsive therapy (ECT) in inpatient settings whereby, as mentioned, the authors note that ECT is known for a high risk of cognitive impairment, but associated with a shorter length of inpatient admission , 37. WanSimilarly, Zhang et al. (2015) found that among geriatric (aged 60 years and above) inpatients with a primary psychiatric diagnosis, treated in Beijing between 2007 and 2013; 24.2% of those enrolled in either the UE-BMI, UR-BMI or GIS schemes received ECT compared to 46% among the uninsured group . Those wTo visualize differences in mental health utilization across the health insurance mechanisms, simple bar charts were prepared, and these are provided as an Additional File  speaks to the limited nature of the current evidence base. Overall, findings demonstrated that enrollment in SHI or NHI schemes increased utilization of mental health care. This was consistent for the length of inpatient admissions, the number of hospitalizations, outpatient use of rehabilitation services, having ever received treatment for diagnosed schizophrenia and depression, compliance with drug therapies and the prescription of more favorable medications and therapies when compared to the uninsured. However, following the approach of other systematic reviews which explored the impact of insurance enrollment on health care utilization, it was difficult to draw overall judgements on whether the impact of insurance enrollment was positive or negative for mental health care outcomes , 23, 24.There were some notable exceptions to these overall trends. For example, in Chile, outpatient mental health consultations were less frequent among those enrolled in the SHI in comparison to the uninsured and those with private health insurance coverage, despite the prevalence of disorders and severity being higher among those enrolled in the SHI scheme. Since the study was conducted, Chile has embarked upon ambitious reforms towards universal health coverage, referred to as the Regime of Explicit Health Guarantees (AUGE), which provides an entitlement to a certain set of services for all members and was implemented in 2002–03. It remains unclear whether the AUGE reforms have impacted on these trends. Another notable exception was in South Korea, whereby NHI beneficiaries were less likely to be long-stay inpatients (i.e. admitted for longer than 180 days) when compared to Medical Care Aid beneficiaries, who are economically vulnerable and thus the majority, if not all, of their costs are covered by government subsidies. These findings may point to the influence of cost-sharing arrangements under NHI schemes – where a greater share of costs are carried by individuals (i.e. 20% for inpatient care under Korea’s NHI); utilization may be lower - however where a greater share of costs are subsidized and individuals do not make direct contributions to their cost of care, their utilization (or length of stays) were longer . Across all studies, when utilization was defined as the length of inpatient admissions, studies that demonstrated longer length of inpatient admissions for those enrolled in insurance mechanisms did not unpack whether these lengths of stay were warranted based on the severity of the condition, or whether these long lengths of stay indicated some form of inefficiency in the health system. Similarly, without data regarding the severity of conditions, findings that indicate shorter lengths of stay do not directly point to a lack of insurance coverage (and therefore greater out of pocket spending) as a reason for these trends.Thus, whilst the review has demonstrated that enrollment in CBHI, SHI or NHI schemes increases utilization of mental health care compared to uninsured populations; the clinical complexity of mental health care, particularly for severe mental health disorders, compounded by cultural norms around medication use, was also revealed in this review. Other complexities included the implications of a lack of explicit treatment guidelines and mechanisms by which perverse provider incentives can be mitigated. Across studies from China, insurance coverage was associated with the increased prescription of ACM and anti-epileptic medication but the reduced provision of Clozapine and ECT for Schizophrenia; although importantly, prescription for all these drugs across all insurance groups was higher than globally recommended , 42, 43.In addition to the comparison of SHI, NHI, CBHI and uninsured healthcare, reimbursement mechanisms appear to play a critical role. Providers are reimbursed on a Fee for Service (FFS) basis in China, known to create a perverse incentive for excessive or expensive treatments. While FFS still prevails, province- and city-based reforms in China have explored capitation, pay-for-performance (PFP), and diagnosis-related groups (DRGs) for inpatient care , 47. SwiWhile the evidence may suggest that the uninsured are provided with unnecessary treatments in order to reduce their length of admission, the longer inpatient stays and increased numbers of hospitalizations amongst the insured may not necessarily be indicative of improved service quality or appropriate access. The large focus of the papers on inpatient mental health care utilization and severe mental health conditions may speak to a lack of developed outpatient and community based services; it may also point to the explicit inclusion of inpatient care as part of the benefits package without the explicit inclusion of outpatient services including rehabilitation. Further, as revealed through our secondary review of the insurance mechanisms under evaluation in this study, differences in cost-sharing arrangements for inpatient and outpatient care may lead more mental health care users to opt for inpatient care where a larger proportion of costs are covered, compared to outpatient care where (if available) co-payments are far higher. In the case of South Korea, for example, NHI enrollees face a 20% co-payment for inpatient care whilst they face co-payments ranging from 30 to 60% for outpatient care depending on the level of provider. Prior to reforms in Chile, FONASA enrollees faced up to 15% co-payments for inpatient care provided by the government, with low income groups facing no co-payments – however these enrollees faced important exclusions in terms of the services they were able to access. These findings suggest that in countries pursuing SHI and NHI, inpatient benefits may be more explicitly defined, when compared to entitlements for beneficiaries for outpatient care which may be covered under an umbrella of a primary health care package of services; thus subject to more provider rationing within capitation systems.While countries implementing SHI mechanisms have made considerable progress in improving population health access, social assistance to cover vulnerable populations and cross-subsidization has been integral to achieving UHC . Countrinew AEDs was highest among those enrolled in the CSMBS scheme (31%), with 19% and 13% of those enrolled in the SSS and NHI schemes respectively received new AEDs. Similarly, while 95% of China’s citizens are reported to have basic insurance under one of their three major schemes, only the UE-BMI requires mandatory contributions whilst government subsidies account for 75–85% of the premiums of the other two [In Thailand, hailed to have achieved UHC, largely based on general taxation, disparities exist across its three different insurance schemes, which include the civil servants’ medical benefit and social security scheme and the universal coverage scheme that includes 72% of the population . The stuther two . The lacther two . Prior tther two ; this stGiven the highly stigmatized nature of mental health, amplified by the socioeconomic vulnerabilities experienced by many of those living with mental health disorders, explicitly outlining the inclusion of mental health within national and social health insurance benefit packages is key. Countries such as China and Thailand have made explicit inclusion of mental health during financial reforms including China’s 686 Programme in 2004, named after the initial funding allocation of 6.86 million yuan  . ThailanDespite some guidance by key actors on how countries can improve the design and functioning of their health systems to achieve UHC; countries on their path towards universal coverage are grappling with policy re-definition as well as cost containment, quality of care, equity, and regulatory considerations. Thus, the achievement of UHC, or at least progress towards it, still has not led to a major conversion between different countries when it comes to access and quality of service delivery. A review of lessons from 11 countries implementing UHC highlights its complexity . The stuThe assessment of UHC within countries implementing NHI or SHI mechanisms is challenging given that the available evidence rarely explores the causal links between the design features of the schemes and the outcomes observed . In pracHealth-related outcomes  are affected by many more variables than UHC alone. UHC schemes may improve access by making services more affordable but they may not influence.other dimensions of access such as limited availability of services or limited acceptability of existing health services.UHC in itself does not have a direct impact on health but rather impacts on individual or household utilization of health services by reducing the financial barriers to access. Impact evaluations should therefore concentrate on measures of health status that can be attributed to this increased access to health. Furthermore, the impact of UHC schemes may vary across different populations, in which the impact of reducing direct payments on utilization might be stronger for poorer populations. Similarly, the impact of UHC schemes on nonmedical consumption, which represents a proxy for financial protection, may also be stronger among poorer households. Most research focuses on horizontal equity with regards to using equity of utilisation as a proxy indicator for equity of access. As such, research focuses on services and interventions for which there is readily available data at the expense of adequately defining or measuring unmet need for the most marginalized and disadvantaged populations , this is, “equitable access is seen as the experiences and interactions of different socioeconomic groups with the health care system, within the broader context of the structural inequities that define social hierarchies and hence determine differential health needs” .Frenz et al. (2019) have developed an analytical framework for assessing equity of access in UHC policies by reflecting on both demand and supply side factors . With thFurthermore, UHC schemes are not homogeneous interventions, even within countries, and despite them having a common goal, implementation varies. Complimentary schemes co-exist which vary with regards to the degree of coverage of services, levels of copayments, conditions of access and time of implementation-all likely to impact health outcomes. In addition, the lack of access to a UHC scheme cannot be assumed to be equivalent to the total lack of coverage in all settings, as UHC schemes may supplement or overlap with already existing publicly financed health systems. It is therefore important to carefully take into account this overlap when designing impact studies and interpreting their results .The majority of papers included in the review did not describe the insurance schemes and their organizational details at length, nor did they define the explicit mental health entitlements for mental health care users, with limited discussion of the potential links between these features and the outcomes. As such, inferences were made by the authors of this paper based on the additional literature review. Despite the difficulty in establishing the impact of the individual financing functions of the insurance schemes on mental health utilization there is an association between increased mental health service utilization and increased insurance enrollment, likely largely because of the removal of financial barriers to access.To the best of our knowledge, this systematic review is the first of its kind to systematically explore effects of health insurance schemes on mental health service utilization in LMICs. Further, it has facilitated a collection of supplementary data on health insurance schemes in countries of included studies. Despite some heterogeneity between countries, this review has demonstrated that the pursuit of NHI and SHI as a means of achieving UHC has the capacity to improve service utilization for MNS disorders.This review has several limitations that are worthy of note. Firstly, only studies available in English were included. Secondly, the study did not examine whether improvements in utilization were pro-poor, nor did we take into account the mental health outcomes or severity of illness that may impact utilization as this information was not provided by the majority of included studies. Furthermore, given the cross-sectional nature of the majority of studies, only associations between insurance enrollment and mental health care utilization could be made, and causality could not be proved. In addition, studies that depended on self-reporting stood the risk of recall and social desirability bias. Future research must include a wider documentation of the impact of mental health care utilization among all countries adopting reforms toward UHC, with an explicit focus on how countries have altered their funding sources, pooling arrangements, purchasing methods, and policies on benefits and patient cost-sharing to achieve better mental health care utilization.Despite the fact that many LMICs have been hailed for financing reforms towards universal health coverage, it is surprising that evidence on the impact of the reforms on mental health care utilization is only available for a small sub-set of these countries, namely Thailand, China, South Korea and Chile. In addition there was very limited examination of the impact of enrollment on outpatient and community-based mental health care; LMICs transitioning to financing systems that pursue the goal of universalizing health care inclusive of mental health care do not yet have sufficient evidence to guide decision making on how to make the best use of available resources in order to achieve UHC, including considerations of the redistribution of resources from hospi-centric care to the community; task-shifting mental health care to non-specialist providers who receive ongoing specialist supervision; the initiation of early interventions that are accessible to at risk populations; integration of mental health in broader primary health care , 60–67. Additional file 1.Additional file 2.Additional file 3.


Field of Medicine: Personalized and precision medicine (PPM)Audience: The book provides a detailed overview of PPM workflows, targeting primarily informaticists. Nevertheless, it can be also useful to any health care professionals, students, or scientists interested in PPM.Purpose: As outlined by the editors in the introductory chapter, the book was written with the following three objectives in mind: 1) “to review the present state of the art in PPM and the associated PPM informatics, and especially to map out all major forms of PPM and systematize them for better understanding and communication”, 2) “to review trends and future developments in PPM and PPM informatics and outline concrete areas of high value research in PPM informatics,” and 3) “to provide a consolidated and up to date PPM survey that can assist with the training of PPM researchers and practitioners .”Contents: The book contents are divided into five parts, including an introductory chapter, three main parts, titled “Classical PPM,” “Emerging PPM,” and “Integrative Informatics for PPM,” and a conclusion.The introductory chapter familiarizes the reader with the field and definition of PPM, outlines the book's purpose, and lists its main objectives. This chapter also provides a short overview of the contents of the three main parts.The second part of the book, titled “Classical PPM,” addresses the well established use of PPM and associated informatics, namely informatics methods and workflows used for clinical risk assessment, outcome prediction and subsequent decision making, principles of clinical genetics and genetic counseling, and fundamentals of pharmacogenomics workflows. The first chapter concerning risk assessment provides an overview of early PPM modalities and the basics of disease severity and risk modeling, such as prediction models, their evaluation, new risk factor selection, and methods that facilitate model interpretation. The second chapter describes the principles of guideline-driven PPM informatics in a case study where an informatics framework for electronic health records is developed for clinical decision making in patients with hypertension. The chapter focusing on the principles of genetic counseling provides a general workflow for clinical genetic assessment and explains the terms used in genetic testing. It lists the fields where PPM informatics use is currently well implemented, brings to attention expanding and emerging roles of genetic counselors, and touches on practice guidelines, educational standards, ethical and legal considerations. The field of pharmacogenomics is dealt with in two separate chapters, the first of which provides an introduction to the field and a detailed description of two types of pharmacogenomics workflows in a learning health care system. The other provides an industry perspective, showing how the Mayo Clinic-cofounded startup OneOme and its RightMed pharmacogenomic model-based personalized prescription solution tackle the need for PPM use in drug prescription.The third part of the book, titled “Emerging PPM,” presents the experience of several different authors with emerging PPM workflows. The introductory chapter familiarizes the reader with the concepts and workflows for the development and validation of predictive models for prognosis and risk stratification using big data, and describes the algorithms used in predictive modeling. A separate chapter introduces the concept of molecular profile and describes a workflow for molecular profile-based PPM, including the main principles of informatics used in model selection, fitting, and error estimation. This is followed by a case study detailing the use of this workflow in bevacizumab trials in patients with ovarian cancer. A chapter also describes the architecture of the National Cancer Institute (NCI) transcriptional pharmacodynamics workbench software, a tool that enables biomedical scientists to analyze cancer molecular profiles. Another chapter addresses the application of platform-independent isoform-level gene expression-based classification system (PIGExClass) in two cancer types, and examine the possibilities for isoform-level cancer gene subtyping. A separate chapter focuses on different next-generation sequencing methods used for cancer profiling in precision oncology, and discusses bioinformatic analysis, the main large-scale studies performed in the field, and existing data-sharing networks. The next chapter deals with the need for harmonization of omic data across PPM databases to create larger cohorts for discovery validation, describing the strengths and challenges of such an approach. Besides the examples of workflows used in precision oncology, there is also a chapter presenting the National Institute for Mental Health’s Research Domain Criteria initiative as an example of PPM use in psychiatry. Two chapters discuss the implementation of PPM in clinical trials. One describes how it can be used to overcome some of the obstacles in phase-IV clinical trials by integration of electronic health records, and briefly discusses innovative trial approaches, such as pragmatic trials and drug repurposing. The other focuses on precision trials informatics, meaning the use of PPM in clinical trial design where group assignment is based on biomarker profile. It describes the NCI molecular profiling-based assignment of cancer therapy study, the first study using precision medicine in clinical trials, and the GeneMed precision trial management system design and workflow. This part's last chapter deals with large-scale PPM implementation by Gesinger health care system, a rural integrated health care delivery system in Pennsylvania.The fourth part, titled “Integrative Informatics for PPM,” presents general workflows for the use of genomic data in clinical workflow, the architecture of PPM informatics supporting clinical decision making, and current and future possibilities for education in the PPM field. The first chapter extensively describes the integration of omic data into the clinical workflow by using a model for data translation from bench to bedside, highlighting cost considerations and ethical and legal issues. The next chapter depicts the general architecture of PPM informatics for clinical decision making and its components, providing examples of single-institution and large-scale implementation of pharmacogenomics. Another paradigm of informatics architecture for large-scale PPM implementation is given in a separate chapter describing Geisinger’s ProvenCare model used in cardiac surgery. The fourth part ends with a chapter about PPM informatics training, which lists the prerequisites, core competencies, and various forms and levels of PPM education.The fifth part summarizes the current state of PPM; the challenges of its large-scale implementation; touches on economics, education, and ethical and legal issues; and discusses future PPM opportunities.Highlights: The review of the currently used and emerging PPM workflows provides the reader with a comprehensive and detailed survey of PPM. Various authors describe PPM workflows from informatics methods to implementation by a practicing physician. Besides workflow presentation, several chapters include case study examples. Detailed workflow descriptions are often supplemented by graphical representations, an approach that enables readers to more easily follow the text. Even though the book is written primarily for readers with a background in informatics, it can also be useful to any health care worker or scientist interested in PPM.Related Reading: Important related reading from the field of PPM is cited in the reference section of the Introduction chapter. Additionally, every chapter contains its own reference section.