World Health Day 2022 – Our Planet, Our Health – CEPS Research

Vicky Jackson and Zac Richardson
This post was written for the CEPS and School of Economics, University of Bristol blog pages.

On World Health Day we are highlighting the work of colleagues in the School of Economics and the Centre for Evidence Based Public Services (CEPS). This year, World Health Organisation (WHO)’s theme is ‘Our Planet, Our Health’ and focuses on the interrelated challenges of health and the environment. In particular, WHO is concerned with highlighting the political, social and commercial decisions which continue to drive the climate and health crisis. With this year’s theme they seek to challenge the present design of the economy which leads to inequitable distribution of income, wealth and power. Instead, they propose the development of sustainable well-being societies committed to achieving equitable health now and for future generations without breaching ecological limits.

Here at the School of Economics our agenda includes health, education, welfare reform, urban planning and the environment with an emphasis on data-intensive research that delivers practical solutions to real-world problems. Inequality is a key theme within economics, so it should be no surprise that our research tackles the sources and consequences of inequality. Our research and policy recommendations are intended to change everyday decisions we make, including working towards fairer, more equitable and sustainable societies through the improvement of public services. We are proud of the research and analysis that colleagues have produced, a list of recent research on health and the environment can be found at the end of this blog. Our wider research activity can be explored here.


Our health research covers a range of topics, including the efficiency of healthcare delivery and individual and household decision-making in relation to health and healthcare. Much of our research focuses on the co-dependence between health and economic outcomes, exploring how shocks to health and well-being affect outcomes such as educational attainment and employment, as well as vice versa.  In a recent paper, Born on a Busy Day: Midwives Buffer Effects of Crowded Wards on Babies and Mothers, Hans Sievertsen and co-authors assessed the impact of crowded wards using a study of nearly 800,000 births to look at maternity wards. They found midwives adjusted their care strategies for mothers to ease workload pressure during busy periods. Surprisingly, the shifts in treatment brought no obvious signs of harm to mother and child. Patrick Gaule and co-author have examined what the research and development response to COVID-19 tells us about medical innovation and how lessons from the response could be used to scale up innovation to confront other deadly diseases as well as global challenges like climate change. While economists tend to see market size as the main driver for innovation, they argue a broader perspective that takes the greater good into account is needed. The response to the pandemic shows that when the incentives are right innovation can proceed at a very fast pace.

In her recent paper “The impact of health on labour supply near retirement”, Monica Costa-Dias and co-authors assessed the role of different measurements of health in the estimation of the impact of health on employment. Accurately capturing this relationship has important implications for targeted policy to help reduce inequality. Amongst their conclusions they found that health is a more important driver of employment among those who left education earlier. Jeremy McCauley has studied the link between dementia and disadvantage in the USA and England. He and his co-authors found inequality in dementia prevalence according to income, wealth and education in both the USA and England. Overall, England has lower dementia prevalence and a less strong association with socioeconomic status. Most of the difference between the two countries is concentrated in the lowest socioeconomic group, which suggests disadvantage in the USA is a disproportionately high-risk factor for dementia.

Researchers also looks at household and individual decision-making in relation to health and healthcare aiming to make policy recommendations for individual and societal good. Christine Valente’s main research interests lie in household decisions regarding fertility and human capital investments in developing countries: “Provide women with information about the risk of pregnancy to increase contraceptive demand.” Her research into contraceptive use found women in the South of Mozambique generally hold accurate or plausible beliefs about the effectiveness of contraception, but that they underestimate the risk of pregnancy in its absence. Addressing this underestimation, rather than focussing solely on free contraception is key to reducing unwanted pregnancies. She has been awarded a major grant from the Bill and Melinda Gates Foundation to continue this research with a major study in Nigeria.

Patrick Arni and colleagues examined ‘biased health perceptions’, that is how people overestimate their health and how these misperceptions are strongly linked to unhealthy behaviours: Overconfidence in Health Linked with Unhealthy Lifestyles According to Economic Report. The findings point to several potential public health interventions: those with biased health perceptions could be targeted for public health campaigns aimed at reducing risky health behaviours. Regular health check-ups and screenings, in addition to nudging people to seek regular feedback about their health, could also be effective. Stephanie von Hinke also studies the economics of obesity, diet and nutrition, looking at both potential causes and consequences of the recent rise in body weight, as well as at evaluating ways to improve dietary choices. With Eleonora Fichera she has written on nutrition labelling, evaluating the impact of the introduction of front of packet nutritional labels on households’ shopping baskets in the UK. They found that the introduction of labelling did affect households’ food choices, and also led manufacturers to improve the healthiness of their labelled products. They recommended the widening of food labelling across more products and more food retailers.

Stephanie also investigates the importance of genetics, early life environments, parental investments, and government policy in explaining individuals’ health and well-being over their lifetimes. She currently holds an ERC Starting Grant, “Developmental Origins: exploring the Nature-Nurture Interplay,” which explores these questions. Her recent CEPS blog Genes and Upbringing Both Matter for Educational Success highlighted this nature-nurture interplay as inextricably linked in a study finding that eldest siblings, typically blessed with extra attention from their parents, do especially well in education when they also possess certain genetic traits. In a recent working paper, “The Long-Term Effects of Early-Life Pollution Exposure: Evidence from the London Smog” Stephanie von Hinke and Emil N Sørensen used information on exposure to the London smog of 1952 to investigate the impact of early-life pollution exposure on individuals’ human capital and health outcomes in older age. They found those exposed to the smog have substantially lower fluid intelligence, the ability to think and reason abstractly and solve problems, and worse respiratory health.

See Stephanie Von Hinke discuss her work on Economics and Genetics in this Bristol Talk Economics talk.


Our environmental research evaluates the effects of transport infrastructure investments, as well as using house price responses to transport and environmental policies as a method of valuing their perceived costs or benefits. Other research covers the pricing policies of airports and looks at urban development in multiple country settings.

Yanos Zylberberg and colleagues’ work examines pollution and spatial inequalities in relation to urban expansion. In a recent article, “East Side Story: Historical Pollution and Persistent Neighbourhood Sorting,” they explored historical pollution patterns and their impact on urban development. They found past pollution explains up to 20% of observed neighbourhood segregation and spatial inequalities in 2011, even though coal pollution stopped in the 1970s.

Yanos’s current Open Research Area funded project:  MAPHIS: What Historical Maps Can Tell Us About Urban Development will advance our understanding of long-run urban growth through the digitisation and examination of historical maps spanning almost a century. It will explore the historical evolution of urban neighbourhoods from 1870 onwards and help us better understand how urban planning decisions made today affect the cities of tomorrow. A striking feature of cities around the World is the large differences in neighbourhood composition, which may reflect segregation fuelled by rural-urban migration and unequal exposure to environmental dis-amenities. Little is known about the patterns of city development during the structural transformation of economies, MAPHIS will seek to address this.

See Yanos Zylberberg talk about his current project, MAPHIS.

He has also studied the impact of nuclear power plant development on local areas by examining the effect of the 2011 Fukushima disaster on property prices in England. They found that property prices fell, and deprivation rose in neighbourhoods near nuclear-power plants as richer residents left the area. The study has implications for policies aimed at reviving local areas and suggests that areas with highly mobile workers are less resilient in the face of local shocks.

Helen Simpson’s research covers urban economics and the effects of place-based policies. She currently holds a British Academy Fellowship for her project “Cities, productivity and levelling up”. This will investigate whether the COVID-19 pandemic is likely to have long-term effects on where people in some occupations live and work. These choices, as well as decisions by firms on what now constitutes the workplace, could have implications for UK cities and regional economic inequality. While the direct effects of the pandemic will likely amplify existing spatial inequality in the UK, any acceleration towards working, and spending, from home may also affect affluent cities and the extent to which they derive benefits from density. Helen’s project will map these trends and their impact on local economic performance, drawing out implications for the ‘levelling up’ agenda.

Economics can provide the tools and evidence to help challenge the political, social and commercial decisions we continue to make that are driving the climate and health crisis. Economics can also shape the development of new more sustainable societies providing equitable health now and for future generations without breaching ecological limits. Here at the School of Economics and CEPS our researchers will continue to contribute to these critical conversations.

Recent Research by the School of Economics and CEPS on Health and the Environment 

Ruchir Agarwal, Patrick Gaule, ‘What does the R&D response to Covid-19 tell us about innovation?,’ Economics Observatory [Blog], 6 September 2021, 


Ruchir Agarwal, Patrick Gaule, ‘What drives innovation? Lessons from COVID-19 R&D’, Journal of Health Economics, Volume 82, 2022, 102591, 


Karolos Arapakis, Eric Brunner, Eric French, Jeremy McCauley, ‘Dementia and disadvantage in the USA and England: population based comparative study’. BMJ Open, 11(10) (2021).  


Karolos Arapakis, Eric French, John Bailey Jones, Jeremy McCauley ‘On the Distribution and Dynamics of Medical Expenditure Among the Elderly’. (2021). University of Michigan Retirement and Disability Research Centre Working Papers. 436. 


Patrick Arni, Davide Dragone, Lorenz Goette, Nicolas R. Ziebarth, ‘Biased health perceptions and risky health behaviors—Theory and evidence,’ Journal of Health Economics, Volume 76, 2021, 102425,   


Patrick Arni, Michelle Kilfoyle, ‘Overconfidence in Health Linked with Unhealthy Lifestyles According to Economic Report,’ CEPS [Blog] 10 November 2021.  


Pietro Biroli Titus Galama, Stephanie von Hinke, Hans van Kippersluis, Cornelius A. Rietveld, Kevin Thom, ‘Economics and Econometrics of Gene-Environment Interplay,’ 25 February 2022, School of Economics, University of Bristol Working Paper Series wp22/759.  


Tom R.P. Bishopa, Stephanie von Hinke, Bruce Hollingsworth, Amelia A.Lakee, Heather Brown, Thomas Burgoine, ‘Automatic classification of takeaway food outlet cuisine type using machine (deep) learning’, December 2021, Machine Learning with Applications, vol 6, 2021. 


Bernard Black, Eric French, Jeremy McCauley and Jae Song. ‘The effect of disability insurance receipt on mortality’. 16 November 2017. 


Richard Blundell, Jack Britton, Monica Costa Dias, Eric French, ‘The Impact of Health on Labour Supply Near Retirement’, The Journal of Human Resources, 19 January 2021,  


Eleonora Fichera, Stephanie von Hinke, ‘The response to nutritional labels: Evidence from a quasi-experiment,’ Journal of Health Economics, Volume 72, 2020, 102326, 


Eric B. French, John Bailey Jones, Elaine Kelly, Jeremy McCauley, ‘End of Life Medical Expenses’. 22 September 2019. VoxEU CEPR Blog. 


Eric B. French John Bailey Jones, Elaine Kelly, Jeremy E Mccauley, End of Life Medical Expenses. in Handbook of Aging and the Social Sciences . 9 edn, Academic Press. 


Eric B. French, Jeremy McCauley, et al. ‘End-Of-Life Medical Spending In Last Twelve Months Of Life Is Lower Than Previously Reported’. July 2017. Health Affairs, vol. 36. 


Stephan Heblich, Alex Trew, Yanos Zylberberg, ‘East Side Story: Historical Pollution and Persistent Neighborhood Sorting’. Journal of Political Economy, 129(5), 1508-1552. 2021. 


Jonas Maibom, Hans H. Sievertsen, Marianne Simonsen, Miriam Wüst, ‘Maternity ward crowding, procedure use, and child health’, Journal of Health Economics, Volume 75, 2021, 102399, 


Loubaba Mamluk, Timothy Jones, Sharea Ijaz, Hannah B Edwards, Jelena Savović, Verity Leach, Theresa H M Moore, Stephanie von Hinke, Sarah J Lewis, Jenny L Donovan, Deborah A Lawlor, George Davey Smith, Abigail Fraser, Luisa Zuccolo, ‘Evidence of detrimental effects of prenatal alcohol exposure on offspring birthweight and neurodevelopment from a systematic review of quasi-experimental studies’, International Journal of Epidemiology, Vol 49, December 2020.


Steven Proud, ‘Funding Social Care’, Bristol Economics Blog, 7 September 2021. 


Mohammad Mahbubur Rahman, Saseendran Pallikadavath, Rabeya Khatoon. ‘Does Shorter Postnatal Hospital Stay Lead to Postdischarge Complications? An Instrumental Variables Approach’. 14 April 2019. Journal of International Development, vol. 31, 5. 


Han H. Sievertsen, Michelle Kilfoyle, ‘Born on a Busy Day: Midwives Buffer Effects of Crowded Wards on Babies and Mothers,’ CEPS [Blog], 24 November 2021. 


Hans H. Sievertsen, CT Kreiner. ’Neonatal health of parents and cognitive development of children’ January 2020. Journal of Health Economics, vol. 69, 102247. 


Christine Valente, Grant Miller, Áureo de Paula, Páscoa Zualo Wate, ‘Provide women with information about the risk of pregnancy to increase contraceptive demand’, Policy Briefing 82: March 2020, Policy Bristol. 


Christine Valente, Grant Miller, Áureo de Paula, ‘Subjective Expectations and Demand for Contraception,’ July 2021  


Nicolai Vitt, Martina Vecchi, Jonathan James, Michel Belot, ‘Daily Stressors and food choice: Evidence from a lab experiment with low SES mothers’ (2021), European Economic Review, vol 136, January 2021. 


Nicolai Vitt, Martina Vecchi, Jonathan James, Michel Belot, ‘Maternal stress during pregnancy and children’s diet: Evidence from a population of low socioeconomic status’, (2021), Nutrition, vol 93, January 2021. 


Stephanie von Hinke, ‘Education, Dietary Intakes and Exercise’ 23 June 2021, University of Bristol Working Paper Series wp21/748. 


Stephanie von Hinke and David Avdic, ‘Extending alcohol retailers opening hours: Evidence from Sweden’ (2021), European Economic Review, vol 138, November 2021. 


Stephanie von Hinke, ‘Gene-Environment Interplay in the Generation of Health and Education Inequalities’, NORFACE, 2022. 


Stephanie von Hinke, Michelle Kilfoyle, ‘Genes and Upbringing Both Matter for Educational Success,’ CEPS [Blog], 17 December 2021  


Stephanie von Hinke, Emil N Sørensen, ‘The Long-Term Effects of Early Life Pollution Exposure: Evidence from the London Smog,’ 18 February 2022, School of Economics, University of Bristol Working Paper Series wp22/757.  


Stephanie von Hinke, Eleonora Fichera, ‘Nutrition labelling helps individuals choose healthier foods,’ Policy Briefing 94: Nov 2020, Policy Bristol. 


Yanos Zylberberg, Michelle Kilfoyle, ‘Study Reveals How the Flight of the Rich from Homes Near Nuclear Power-Plants Brings Local Deprivation,’ CEPS [Blog], 27 October 2021.    

Why We Give to Charities and When: Fundraising Lessons From Health Scares and International Disasters

Sarah Smith and Michelle Kilfoyle
22 December 2021

Charities have taken a huge hit in income during the Covid-19 pandemic. Social distancing has prevented in-person fundraising events, whether fun runs or cake sales, while lockdowns forced charity shops to shut their doors to customers for months at a time.

Of the funding that has made it to charities, there has been a notable shift in donations towards hospital and hospice charities, and away from non-Covid-19 causes.

Our research provides fresh insights for the charitable sector that could shape fundraising strategies and help boost income across the sector post-pandemic.

Lifting or shifting donations?

Fears circulate in the charitable sector that when we give money to one charity, it comes at the expense of donations to others. After all, there is only so much money and, perhaps, good will to go round. But is that really the case? Or can we be inspired to both give more, and give to more charities? Providing evidence from health charities and disaster appeals, research by Sarah Smith from the Centre for Evidence-based Public Services (CEPS) in Bristol’s School of Economics addresses this debate. It shows that there are instances of givers shifting their donations between different charities, and also examples where they expand the number of charities they support.

Health charity donations after severe illness

People who have survived a severe health scare are more likely to donate to related medical charities following their diagnosis, a phenomenon known as ‘altruism born of suffering’. A study by Smith and colleagues from Monash University provides evidence on the rate of its occurrence and, shows that this giving does divert spending away from non-health causes.

The research team analysed long-term data (2001-2015) on over 400 households across the US who were asked about their charitable giving and about their health.

In the year following a health scare, namely cancer, a heart attack or a stroke, the probability of donating to health charities went up by 11 percentage points, that is, 41% of this group donated, compared with 30% among those who had not had a health scare. Their likelihood of donating to health charities drops as the years pass, but still remains 6 percentage points higher 2-3 years after the scare.

These donors subsequently gave less money to non-health charities – switching loyalties between good causes, but were not giving more or supporting more charities overall.

Further, the health scares rarely motivated people to give to health charities if they were not already regularly donating to charity. Only 4% of new givers to the health sector had never donated to non-health causes prior to their health shock.

Disaster relief appeal effects on total giving A separate, but related, study revealed very different patterns of giving in the case of disaster relief campaigns in the UK.

Unlike the case of health charities and health shocks, disaster relief appeals trigger a lift in overall donations. People not only give to the campaigns over and above their existing charitable donations, but also go on to donate to other charities that are quite separate to the disaster relief campaign – at least in the short term.

Smith and colleagues from the University of Birmingham and IUPUI in the US studied data on the charitable giving accounts of more than 100,000 UK people who regularly donate through the Charities Aid Foundation (CAF), covering 4.5 million donations to 80,000 charities over 2009-2014.

They focused on six major appeals launched during this time by the UK Disasters Emergency Committee (DEC), including the 2010 earthquake in Haiti and the 2013 typhoon in the Philippines.

Significant spikes in overall donations through CAF were seen after each of these appeals; of the five biggest spikes over the period, four occur after DEC appeals.

Total donations were higher for 14 weeks after each appeal, before returning to normal levels.

Strikingly, donations to other, non-DEC, charities also increased by 10% immediately after each appeal, and these all came from the same people who had given to DEC.

This donation pattern is not unique to DEC appeals. The study found similar results for major annual fundraising telethons, specifically BBC Children in Need, Comic Relief and Sports Relief, where a lift in non-telethon donations also occurred immediately after the events.

A few weeks after the DEC appeals, donations to non-appeal charities dipped below typical levels before returning to normal. However, there was no subsequent drop in donations to non-appeal charities after telethons, suggesting that the degree to which people adjust donations varies by charitable cause.

Altruism vs ‘warm glow’

Smith and colleagues explain the different patterns of charitable giving in the two studies through different motivations for giving.

Health shocks are an intensely personal experience, often life-changing, and donations to health charities are explained by altruistic motivations. The donor cares deeply about the outcomes of the charities’ activities, such as new medical treatments.

Health charities could focus fundraising efforts with patients in the first year following diagnosis, the research suggests, when the salience of the illness and sense of altruism are at their peak.

Giving to disaster appeals and telethons, on the other hand, is explained by a ‘warm glow’ effect. This is the feel-good factor we experience when we help other people. Thus, increased donations to non-DEC and non-telethon charities occur not only because the appeals have acted as a reminder to give to charity, but also because they extend that warm glow feeling.

Building on these findings, the researchers developed a model that tracks the changing influence of warm glow on giving. When the warm glow effect is high, people find giving to charities relativelyeasier, as shown by the disaster appeal research. But when it is lower, perhaps depleted after a string of donations, the cost of giving to charity feels much greater.

The model helps paint a picture of how charities influence each other’s incomes through their collective effects on warm glow and points to how they could best benefit from this. The model could, for example, identify the best timings for campaigns in relation to one another, as well as the timing or targeting of government tax incentives to encourage charitable giving

Professor Sarah Smith – University of Bristol, School of Economics
Michelle Kilfoyle – CEPS Science Writer

Genes and Upbringing Both Matter for Educational Success


Stephanie von Hinke and Michelle Kilfoyle

Nature vs. nurture is an age-old debate. Are we products of our genes or of how we were raised? It is now widely accepted that both genes and environment are inextricably linked and jointly mould our lives. A recent study of siblings and their educational achievements provides evidence to further bolster this joint gene-environment theory. It finds that eldest siblings, typically blessed with extra attention from their parents, do especially well in education when they also possess certain genetic traits.

Firstborn children have the luxury of their parents’ undivided attention until the arrival of their younger siblings. In fact, firstborns can expect to have, on average, 20-30 minutes more daily quality time with their parents than laterborns, as parents find their time increasingly stretched with each child.

This privilege goes a long way in explaining why eldest siblings tend to do better at school than their younger siblings and can be seen as a form of investment by parents in their child’s future. However, it is not always the full story, as the study co-authored by Stephanie von Hinke of the University of Bristol’s Centre for Evidence-based Public Services (CEPS) in the School of Economics shows.

In an innovative step for economics, von Hinke and collaborators from Erasmus University Rotterdam used genetic data to help understand why some people do better than others in education. They analysed DNA from UK Biobank, a national repository of biological samples and individual data, for a sample of 14,850 adult siblings (aged 40-69 at the time of study).

They measured each sibling’s ‘genetic endowment’ for educational attainment using ‘polygenic scores’. These scores are based on specific genetic variants that correlate with educational attainment.

By comparing siblings from the same family, the researchers were able to cancel out the effects of factors like parental income and social class on children’s educational attainment. (It would be much more difficult to disentangle these wealth and class-derived influences from other non-genetic factors when comparing children from different families.)

Each family was akin to a controlled experiment that allowed the researchers to explore the relative influence of each child’s genetic variation and their environment. In this study, being firstborn or laterborn was used as a measure of a child’s environment as it, at least partly, indicates whether parents invested more or less time in each child.

The results first confirmed that genetic variations are very good at predicting educational attainment. In general, the higher a person’s genetic endowment, the more years they had spent in education. Firstborns were no more or less likely to have a high endowment than laterborns.

Second, the results confirmed that firstborns do better at school. Firstborns with an average genetic endowment completed, on average, an extra 4.5 months of schooling than their laterborn siblings.

However, firstborns who have an above-average genetic endowment completed, on average, an additional two months of education (on top of the 4.5 months) than their laterborn siblings with the same genetic endowment.

This study shows that neither genetics nor environment are solely responsible for determining our education, and that both matter. Furthermore, as well as emphasising the importance of investing in skills early in life, the research supports the idea of ‘dynamic complementarity’ between nature and nurture in this setting, that is the idea that people with higher initial skills benefit more from subsequent investment.

Professor Stephanie von Hinke – Professor of Economics, University of Bristol School of Economics
Michelle Kilfoyle – CEPS Science Writer

Born on a Busy Day: Midwives Buffer Effects of Crowded Wards on Babies and Mothers

Hans Sievertsen and Michelle Kilfoyle
22 November 2021

The recent demands of Covid-19 have seen hospital patient numbers soar. A better understanding of how crowding on wards affects treatments and patient outcomes is essential in helping clinicians best allocate their care – both during the pandemic and beyond, and for all sectors of hospital care. Taking maternity wards as an example, a recent Danish study of nearly 800,000 births finds that midwives adjust their care strategies for mothers to ease workload pressure during busy periods. Surprisingly, the shifts in treatment – fewer inductions and later admission to hospital – bring no obvious signs of harm to mother and child.

Evidence on the effects of crowding is scarce, especially for maternity wards. Much like A&E, maternity wards face the challenge of unpredictable admission rates that are hard to plan for. The new study, by Hans Sievertsen from the University of Bristol’s Centre for Evidence-based Public Services (CEPS) and School of Economics, starts to fill this knowledge gap for maternity wards.

Working with a team of researchers from Aarhus University and the University of Copenhagen, Sievertsen analysed birth registry and medical data for 796,416 babies born during 2000–2014 and their mothers across Denmark. They focused on uncomplicated births, thus excluding those born by planned caesarean.

The research team assessed how treatment and patient outcomes varied according to the number of patients admitted to a maternity ward for each day. Admissions can substantially and rapidly fluctuate on Danish maternity wards, and surges of 200% above the average are not uncommon.

As an example of how patient numbers vary, daily admissions on Denmark’s busiest maternity ward, Hvidovre, range between six and 25.

Their results showed that midwives appear to ease pressure on busy days by choosing not to speed-up delivery by avoiding or postponing inductions. For each three additional admissions over the average, there was a 0.7 percentage point reduction in the number of inductions. This corresponds to a 4% reduction on the average induction rate of 18.6% across all the births studied.

In addition, midwives appear to admit mothers into hospital at slightly later stages of labour during busy periods, thus reducing the overall length of time that mothers spend in hospital.

Of surprise to the research team, crowding presented no obvious health risks to either mother or baby, based on various measures of wellbeing and indicators of care.

For instance, there was no increase in stillbirths or death rates among babies within the first week and year of life. It should be noted that these are rare occurrences in any case, and the study only looked at non-risky births.

For babies, there was no effect on their APGAR score – the quick health test performed immediately after birth to assess five key factors, including breathing and heart rate.

For mothers, there was no increase in the probability of having an emergency caesarean, the rate or severity of lacerations (vaginal tearing), or delay in epidural pain relief. Skin-to-skin contact with baby within two hours of birth, a central quality indicator for Danish hospitals, continued to take place in timely fashion.

Further, children born on crowded maternity wards and their mothers were no more likely than other families to access healthcare – whether GPs or hospitals – in the two years post-birth.

In fact, the study even found that there were fewer serious post-birth complications for mothers who gave birth on busy days: a 1.5% reduction, approximately, for each three extra births over the average. The researchers speculate that this may be because the lower number of inductions on crowded days reduced the need for follow-up treatments associated with this procedure.

The study, therefore, shows that Danish maternity wards’ strategies to ease workload pressure enable midwives to cope with day-to-day spikes and dips in patient numbers, and without detectable health risks for the majority of uncomplicated births. The authors do stress, however, that their results cannot be used as evidence in support of cuts to hospital funding, as they did not examine what the optimal level of maternity care should be.

Hans Sievertsen – Senior Lecturer in Economics – University of Bristol
Michelle Kilfoyle – CEPS Science Writer and Editor

Overconfidence in Health Linked with Unhealthy Lifestyles According to Economic Report

Michelle Kilfoyle and Patrick Arni
10th November 2021

Rising healthcare costs have intensified the focus on nudging the public towards healthier lifestyles. But what if you mistakenly believe your health to be better than it really is? New research shows that many people are just not as healthy as they think they are, and that this overconfidence hikes up the risk of adopting unhealthy behaviours, such as regularly eating junk food or taking no exercise. Public health campaigns that give individuals a better understanding of their true health status could, therefore, help foster healthier lifestyles, the findings suggest.

For economists, health behaviours can be understood in terms of their perceived costs and benefits to the individual. Even if people know that drinking alcohol or eating junk food carries health risks, many still enjoy doing so.

The weight assigned to either cost or benefit is partly shaped by how healthy we consider ourselves to be in the first place and what we believe our bodies can tolerate. We may reason that “I’m healthy enough to ‘afford’ to drink a little alcohol every day” or “I can’t ‘afford’ the health risks of a couch-potato lifestyle”. The study, co-authored by Patrick Arni of the University of Bristol’s Centre for Evidence-based Public Services (CEPS) in the School of Economics, introduces the concept of ‘biased health perceptions’ to describe how people overestimate their health and how these misperceptions are strongly linked to unhealthy behaviours.

As part of an international research team, with colleagues from the Universities of Bologna and Bonn, and Cornell University, Arni analysed data from three large-scale health surveys from Germany which together covered nearly 7,000 adults..

These surveys included objective measures of health, namely blood pressure and cholesterol readings taken by health professionals, which can be used as proxies for physical health. Further, the surveys questioned the respondents on their health to develop a reliable measure of their overall health status, as well as their health behaviours and perceptions of their health.

The research team used these data to calculate the gap, or biased health perception, between actual and assumed levels of health.

They found that 30% of the respondents were unaware that they had high cholesterol, while 9% did not realise that their blood pressure was high.

A clear majority of respondents thought that they were as healthy or healthier than most other people of their age when presented with the question: Imagine randomly selecting 100 people of your age. How many of those 100 people would be in better health than you?.

Thirty percent of respondents placed themselves at least 30 places higher in this ranking system than their overall health status would indicate. If the answers had accurately represented people’s true health, then they would have been spread more evenly across the distribution..

The analysis revealed clear correlations in the data between biased perceptions and behaviours. Respondents who were overconfident in their health were more likely to have unhealthy lifestyles, in that they were more prone to eating junk food, drinking alcohol daily, taking no exercise and not getting enough sleep.

For instance, 54% of the respondents who were unaware that their cholesterol levels were high did no exercise at all, compared with 43% of those who were aware of high cholesterol levels. These biased respondents were also 50% more likely to drink alcohol daily, and to have higher BMIs.

Further, 50% of people who overestimated their health in relation to other people did not exercise at all, compared with the 30% who accurately or underestimated their health.

The findings point to several public health interventions. Those with biased health perceptions could be targeted for public health campaigns aimed at reducing risky health behaviours. Regular health check-ups and screenings, in addition to nudging people to seek regular feedback about their health, could also be effective.

Interestingly, biased health perceptions were not linked to smoking habits. This is probably because addiction to smoking overrides any calculations of costs to health. Hence, public health campaigns that focus on the health costs of smoking are likely less effective at curbing tobacco consumption than tougher regulatory measures, such as smoking bans.

Michelle Kilfoyle – CEPS Science Writer
Dr. Patrick Arni – University of Bristol School of Economics

Study Counts Devastating Toll of Domestic Violence Faced by Mothers on Their Children

Study Counts Devastating Toll of Domestic Violence Faced by Mothers on Their Children

Michelle Kilfoyle and Zahra Siddique – 18 October 2021

Described as the ‘Shadow Pandemic’ by the UN, the global rise in domestic violence against women since the onset of the Covid-19 pandemic is a huge cause for concern. New research further emphasises the urgent need to tackle domestic violence by exposing the scale of its devastating effects on the children of women who suffer at the hands of their partners. The large-scale study, which draws on data from half a million families across the developing world, finds that children born to victims of domestic violence are more likely to die by the age of five than children of mothers who do not. Further, women who experience violence endure more stillbirths.

Even before the pandemic, 1 in 3 women across the world experienced physical or sexual violence mostly by an intimate partner, with rates particularly high in developing regions such as Central sub-Saharan Africa (65.64% of women) and South Asia (41.73%). In 2020, the UN estimated that global cases rose by 20% during lockdown.

This study provides further evidence on the costs of domestic violence by highlighting the damage inflicted upon the wider family, specifically children. Zahra Siddique of the University of Bristol’s Centre for Evidence-based Public Services (CEPS) in the School of Economics, in collaboration with Samantha Rawlings of the University of Reading, analysed the results of 54 Demographic and Health Surveys (DHS) carried out in 32 developing countries between 2000 and 2016.

Collectively, these surveys interviewed around 500,000 women aged 18 to 49 on issues including domestic abuse, births and deaths of children, and pregnancy loss. Interviewers used robust protocols to help participants feel safe and comfortable and maximise the honesty of responses. Twenty-nine per cent of the women reported experiencing physical abuse at some point in their life , while 9% reported experiencing sexual violence.

A host of factors lead to higher death rates among children of mothers who have experienced domestic abuse. In developing countries, families with abusive members tend also to be poorer and less well-educated; all these factors heighten the risk of children dying.

However, Siddique and Rawlings’ research methods allowed them to disentangle the effects of these factors to put precise figures on the damage inflicted by domestic violence alone.

Death rates within the first 30 days of life for children whose mothers experienced physical abuse were 3.7%, compared with 3.0% for children of non-victims. Siddique and Rawlings attribute a significant fraction of this difference – 0.4 percentage points – to the physical abuse. This accounts for around 4,500 deaths among the 1.14 million babies included in this part of the study.

Further, children of domestic-violence victims were 0.7 percentage points more likely to die within a year, and 1.0 percentage points more likely to die within five years of being born. This means that domestic violence led to the deaths of 7,600 babies (of 1.09 million studied) before the age of one, and 8,500 deaths (of 0.86 million children studied) by the age of five.

Most deaths occurred in families where the women experience frequent violence, as opposed to occasional violence.

Further, mothers who experience physical domestic violence were 1.4% points more likely to suffer stillbirth than women who are not victims, with a similar picture emerging for sexual violence.

To help pinpoint the impact of domestic violence on mortality rates, the researchers estimated the influence of ‘unobservables’, that is, differences in characteristics between victims and non-victims that cannot be measured in the data, but can affect mortality rates. They found that the effect of these factors would need to be much larger, by 2-3 times, to be able to completely rule out domestic violence as the cause of the deaths – giving confidence that violence did explain the higher death rates. These behaviours are likely to arise from extreme stress levels, and the study recommends deeper investigation into these factors to better understand the links between domestic violence and childhood mortality.

Michelle Kilfoyle – CEPS Blog Science Writer

Zahra Siddique – Associate Professor of Economics, University of Bristol