Anticipating & assessing adverse consequences of public health interventions - CONSEQUENT framework

Abstract Introduction Despite the best intentions, public health (PH) interventions can have adverse and other unintended consequences (AUCs). AUCs may arise in novel PH interventions, as well as from known and tested PH interventions implemented in a new context. Despite their importance, this topic has been largely overlooked. Therefore, we used a structured value-guided as well as evidence-based approach, to develop a framework to support researchers, practitioners, and policy-makers in anticipating and assessing AUCs of PH interventions. Methods We employed the ‘best-fit’ synthesis approach starting with an a priori framework and iteratively revising this based on systematically identified evidence. The a priori framework was derived from both the WHO-INTEGRATE framework and the Behaviour Change Wheel, to root the framework in global health norms and values, established mechanisms of PH interventions, and a complexity perspective. The a priori framework was advanced based on theoretical and conceptual publications and systematic reviews on the topic of AUCs in PH. Thematic analysis was used to revise the framework and identify new themes. To validate the framework, it was coded against four selected systematic reviews of AUCs of PH interventions. Results The CONSEQUENT framework includes two components: the first focuses on AUCs and serves to categorise them; the second component highlights the mechanisms through which AUCs may arise. The first component comprises eight domains of consequences - health-related, health system, human and fundamental rights, acceptability- and adherence-related, equality- and equity-related, social and institutional, economic and resource-related, and environmental. Conclusions Both over- and underestimation of AUCs of PH intervention poses risks. The CONSEQUENT framework may facilitate classification and conceptualization of AUCs of PH interventions during their development or evaluation to support evidence-informed decision-making. Key messages Despite their importance for evidence-informed decision making adverse and unintended consequences of public health interventions are often overlooked within public health research and practice. The CONSEQUENT framework can support decision-makers in anticipating, assessing, and accounting for adverse and other unintended consquences, as well as the machanisms leading to them.

As the inevitable ageing of the population progresses, the pressure on the public health system increases. The predicted rise in the share of people aged 65 and more from 19% in 2020 to 33% in 2050 jeopardises the capacity of the long term care in Poland. It demands immediate actions in public policies to strengthen the system and to provide the silver generation with the proper and adjusted services. That topic is one of the main issues for the map of health needs, developed by the Ministry of Health in Poland. The analyses investigate the current and future state of this part of the system, e.g. the number of visits, average length of stay, types of services, care-giver support ratio. Conclusions drawn from the data allowed to formulate a number of challenges, which include: 1. levelling up the access to the services, 2. increasing the number of outpatient services, provided at home or close to the place of residence, 3. implementation of the eHealth solutions, 4. support for the informal care-givers.In line with these information, the actions and strategic frameworks have been established at the national level and included: 1. strategic approach for deinstitutionalisation, in order to bring the long term care closer to the patients' environment, to provide them with an optimal level of comfort and to make them self-reliant for as long as possible, 2. enhancement of the inpatient care through transformation of less occupied wards into long term wards in district hospitals.

Key messages:
The Maps of Health Needs help to create national public policies and strategic frameworks aimed at coping with the foreseen challenges of aging society pressuring the healthcare system. The main challenge for the long term care in the future is to channel the available resources in the appropriate way.

Background:
Intermittent Catheterization (IC) is a common procedure used for the management of incomplete bladder emptying in various diseases such as spinal cord injury, multiple sclerosis and benign prostatic hypertrophy. Catheterization is associated with several complications and particularly with an increased risk of developing urinary tract infections (UTIs) responsible for high morbidity worldwide and significant costs to health systems and society.Today, this health problem is still underestimated. Therefore, the aim of this study was to summarize the available evidence on the clinical and epidemiological burden of UTIs among patients performing IC.

Methods:
A systematic literature review was performed querying two online database (PubMed,Web of Science) from January 2012 to January 2022. All studies in English language and focused on the clinical-epidemiological burden of UTIs related to IC in the adult population were included.

Results:
Overall, 43 studies were considered. It was described a range of UTIs from 26% to 63%, with an increased number of hospital admissions and length of stay. UTIs were more common in patients with spinal cord injuries (about 40%) and with multiple sclerosis (24-34%).The main risk factors associated with UTIs were catheter reuse, type of catheter and catheterization procedure adopted.

Conclusions:
Data on IC-associated UTIs are still limited. Estimating the UTIs load in patients with IC could support healthcare professionals to identify the most appropriate type of catheter to reduce the risk of this important complication. Proper management of catheterization could improve patients' quality of life and also reduce the impact of diseases associated with this procedure on health systems and society. Key messages: Catheterization is associated with an increased risk of UTIs causing morbidity and relevant costs to health systems and society.
Knowing the burden of IC-associated UTIs could support better patients management in terms of suitable procedures to apply and more appropriate catheters to use.

Introduction:
Despite the best intentions, public health (PH) interventions can have adverse and other unintended consequences (AUCs). AUCs may arise in novel PH interventions, as well as from known and tested PH interventions implemented in a new context. Despite their importance, this topic has been largely overlooked. Therefore, we used a structured value-guided as well as evidence-based approach, to develop a framework to support researchers, practitioners, and policy-makers in anticipating and assessing AUCs of PH interventions.

Methods:
We employed the 'best-fit' synthesis approach starting with an a priori framework and iteratively revising this based on systematically identified evidence. The a priori framework was derived from both the WHO-INTEGRATE framework and the Behaviour Change Wheel, to root the framework in global health norms and values, established mechanisms of PH interventions, and a complexity perspective. The a priori framework was advanced based on theoretical and conceptual publications and systematic reviews on the topic of AUCs in PH. Thematic analysis was used to revise the framework and identify new themes. To validate the framework, it was coded against four selected systematic reviews of AUCs of PH interventions.

Results:
The CONSEQUENT framework includes two components: the first focuses on AUCs and serves to categorise them; the second component highlights the mechanisms through which AUCs may arise. The first component comprises eight domains of consequences -health-related, health system, human and fundamental rights, acceptability-and adherence-related, equality-and equity-related, social and institutional, economic and resource-related, and environmental.

Conclusions:
Both over-and underestimation of AUCs of PH intervention poses risks. The CONSEQUENT framework may facilitate classification and conceptualization of AUCs of PH interventions during their development or evaluation to support evidence-informed decision-making.
Key messages: Despite their importance for evidence-informed decision making adverse and unintended consequences of public health interventions are often overlooked within public health research and practice. The CONSEQUENT framework can support decisionmakers in anticipating, assessing, and accounting for adverse and other unintended consquences, as well as the machanisms leading to them.

Abstract citation ID: ckac130.219 Tobacco outlet availability in Dutch rural and urban areas
Tessa van Deelen

Background:
The Netherlands aims to reduce the availability of tobacco outlets by implementing a sales ban for vending machines (2022) and supermarkets (2024). The government intends to further phase out tobacco sales by petrol stations and small outlets after 2030. This study aims to understand its impact on tobacco outlet availability in the Netherlands, with particular attention to rural areas.

Methods:
An audit of tobacco retailers was held between Sept 2019-June 2020 in four cities (Amsterdam, Eindhoven, Haarlem, and Zwolle) and between March-Apr 2022 in seven rural municipalities (Aa en Hunze, Ermelo, Dinkelland, Montferland, Simpelveld, Veere, and Waadhoeke). Each identified retailer was visited and mapped using Global Positioning System (GPS). Tobacco outlet availability was calculated in terms of density per population and km2, and residents' proximity to the nearest outlet.

Results:
In the rural areas, we found a total of 98 tobacco outlets, of which supermarkets (n = 57), petrol stations (26), small outlets (13) and tobacco specialist shops (2). In the four cities, we found a total of 870 outlets. Tobacco outlet density was much lower in rural areas than the four cities: 0.09 vs. 2.2 per km2 and 5.05 vs. 6.2 per 10,000 capita. The average shortest distance from an address to a tobacco outlet was much higher in rural areas (1.23km) compared to cities (0.31km).
After implementation of all sales bans, tobacco outlet availability will reduce to 2 outlets in rural areas and 61 in urban areas which represents 0.1 and 0.4 per 10,000 capita, respectively. The distance will increase in cities (to 1.42km), but particularly in rural areas (to 5.28km) where 5 of the 7 municipalities did no longer include a tobacco outlet.

Conclusions:
The proposed restrictions on tobacco sales will strongly decrease tobacco outlet availability, and might even disappear in some rural areas. These results call into question how the tobacco industry would respond to the proposed restriction.

Key messages:
This study is the first ex-ante policy evaluation to assess the impact of current and future tobacco control policies at the POS on tobacco outlet availability in the Netherlands. The proposed restrictions on tobacco sales will strongly decrease tobacco outlet availability, and might even disappear in some rural areas.
Abstract citation ID: ckac130.220 Public perceptions uncovered: engaging in decision-making regarding non-pharmaceutical interventions

Results:
Around 25% of respondents expressed a desire to engage in decision-making, as it would increase understanding and quality of NPIs, and their trust in the government. Especially for the NPIs DCC and NC, respondents found it valuable to engage, by providing their perspective on certain trade-offs in values in decision-making (e.g. opening up society vs division in society by vaccination status). The public could play a role by giving feedback on bottlenecks during decision-making, however overall responsibility should stay with experts and policy-makers. Desire for engagement was lowest for CSD. Around 50% of the respondents did not want to engage, as they felt they were not knowledgeable enough to do so and did not perceive a need to engage. The other 25% had a neutral disposition.

Conclusions:
Engagement was not self-evident for most respondents, yet the ones willing to engage revealed important possibilities for future outbreaks. Next, a deliberative process for PE in decision-making could be executed, in order to implement our findings in practice.

Key messages:
Although engagement was not self-evident, respondents who were willing to engage revealed important possibilities to shape future public engagement practices in decisionmaking in COVID-19 control. Respondents were mostly willing to engage in NPIs with no consensus in the trade-offs of relevant values in decisionmaking, such as the Nightly Curfew and the Digital Covid Certificate.