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Strengthening population health surveillance:

a tool for selecting indicators to signal and monitor the wider

effects of the COVID-19 pandemic

Strengthening population health

surveillance:a tool for selecting

indicators to signal and monitor the wider effects of

the COVID-19 pandemic

AbstractThe COVID-19 pandemic and the actions taken to control the spread of the coronavirus have a substantial impact on population health beyond the morbidity and mortality caused by the virus directly. To provide a comprehensive picture of the impact of the pandemic, suitable indicators for signalling and tracking these wider effects should be incorporated into national monitoring activities related to COVID-19. This document provides a tool for Member States to select suitable indicators for this purpose. It consists of 1) a longlist of mechanisms through which the COVID-19 pandemic influences population health and related indicator areas, 2) a set of important considerations for monitoring the wider effects of the pandemic focusing on health inequalities, data sources, and working with trends, and 3) a list of core indicators that can serve as a practical starting point for Member States for monitoring the wider effects of the pandemic.

This guidance document is part of the WHO Regional Office for Europe’s work on supporting Member States in strengthening their health information systems. Helping countries to produce solid health intelligence and institutionalized mechanisms for evidence-informed policy-making has traditionally been an important focus of WHO’s work and continues to be so under the European Programme of Work 2020–2025.

Keywords:PANDEMIC, INFORMATION MANAGEMENT, HEALTH STATUS, HEALTH CARE, VULNERABLE POPULATIONS

Document number: WHO/EURO:2021-2297-42052-57877

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Contents

ACKNOWLEDGEMENTS .................................................................................................................................IV

INTRODUCTION ..................................................................................................................................................1Background ....................................................................................................................................................1Approach for this tool ..................................................................................................................................1Conceptual framework ................................................................................................................................4

1. LONGLIST OF MECHANISMS AND INDICATOR AREAS ....................................................................6

2. IMPORTANT CONSIDERATIONS FOR MONITORING THE WIDER EFFECTS OF COVID-19 142.1. Indicator disaggregations for identifying health inequalities and vulnerable groups ............142.2. Data sources ........................................................................................................................................172.3. Working with time trends ..................................................................................................................18

3. LIST OF CORE INDICATORS ..................................................................................................................... 19

REFERENCES .................................................................................................................................................... 24

STRENGTHENING POPULATION HEALTH SURVEILLANCE: A TOOL FOR SELECTING INDICATORS TO SIGNAL AND MONITOR THE WIDER EFFECTS OF THE COVID-19 PANDEMICiv

This document was developed by the Data, Metrics and Analytics Unit in the Division of Country Health Policies and Systems of the WHO Regional Office for Europe. The main author is Marieke Verschuuren. David Novillo Ortiz provided direction during the production of the report and technical advice during concept drafting, writing and review. Special thanks to Natasha Azzopardi-Muscat for her strategic guidance.

For further information please contact the Data, Metrics and Analytics Unit ([email protected]).

We thank the following experts for their valuable input during the review process of this document:

WHO

Aasa Hanna Mari Nihlén, Adelheid Marschang, Adrienne Cox, Aigul Kuttumuratova, Ana Carina Jorge dos Santos Ferreira Borges Bigot, Arash Rashidian, Catherine Smallwood, Christine Elisabeth Brown, Daniel Hugh Chisholm, Danilo Lo Fo Wong, Dirk Horemans, Dorota Iwona Jarosinska, Elisabeth Waagensen, Francesca Racioppi, Humphrey Cyprian Karamagi, Ivo Rakovac, Jonathon Passmore, Jozef Bartovic, Jun Gao, Katrine Bach Habersaat, Lin Yang, Maria Neufeld, Mark Landry, Martin Willi Weber, Matthias Franz Wilhelm Braubach, Oliver Schmoll, Pernille Jorgensen, Ruitai Shao, Sarah Thomson, Siddhartha Sankar Datta, Stefania Davia, Susanne Carai, Tamás Gyula Evetovits, Theresa Diaz.

External Experts

Anna Korotkova, Ausra Zelviene, Bosse Petterson, Damir Ivanković, Dionne Kringos, Elena Petelos, Erica Barbazza, Florian Bachner, Gaetan Lafortune, Hanna Tolonen, Heidi Lyshol, Ilze Burkevica, Isabel Noguer, Ondřej Májek, Marina Karanikolos, Marina Shakhnazarova, Marleen De Smedt, Mika Gissler, Mikalai Ramanau, Mircha Poldrugovac, Neil Riley, Niek Klazinga, Nicole Rosenkoetter, Óscar Brito Fernandes, Petronille Bogaert, Véronique Bos.

Acknowledgements

mailto:[email protected]

INTRODUCTION 1

Background

Population health monitoring or surveillance can be defined as the regular and institutionalized production and dissemination of information and knowledge about the health status of a population and its determinants, aimed at informing policy-making (Verschuuren and van Oers (2019)). It is essential for policy-makers to have a reliable and clear picture of how health is distributed in a given population, and what indicators contribute to or reduce opportunities to be healthy. Therefore, surveillance of population health and well-being is the first of WHO’s ten Essential Public Health Operations (World Health Organization (no date a)). During the first phases of the COVID-19 pandemic, the focus of surveillance and monitoring has been on the transmissibility, severity and direct impact of COVID-19, and on public health and health care capacity to inform outbreak management and transformation strategies. However, as has become increasingly clear since then, the COVID-19 pandemic and the actions taken to control the spread of the coronavirus also have an impact on population health beyond the morbidity and mortality caused by the virus directly. These indirect or wider effects include both negative and positive impacts. To provide a comprehensive picture of the impact of the COVID-19 pandemic, suitable indicators for signalling these effects and keeping track of their development should be incorporated into national monitoring activities related to COVID-19. This will inform recovery strategies by enabling development of targeted interventions and effective application of resources to counteract the wider health effects of the COVID-19 pandemic.

Approach for this tool

Aim and structure

The aim of this document is to provide a tool for Member States to select suitable indicators for signalling and keeping track of the wider effects of the COVID-19 pandemic for incorporation into their national monitoring schemes, thus strengthening national population health surveillance in the COVID-19 era. This tool consists of:

y A longlist of mechanisms through which the COVID-19 pandemic influences population health and related indicator areas

y A set of important considerations for monitoring the wider effects of the COVID-19 pandemic: △ Health inequalities and vulnerable groups △ Data sources △ Working with trends

y A list of core indicators.

Introduction

STRENGTHENING POPULATION HEALTH SURVEILLANCE: A TOOL FOR SELECTING INDICATORS TO SIGNAL AND MONITOR THE WIDER EFFECTS OF THE COVID-19 PANDEMIC2

As a first step in developing this tool, a conceptual framework was devised. There are many indirect effects of the outbreak that affect health through various pathways. The conceptual framework logically arranges these pathways, providing a clear and concise thinking aid for identifying and structuring the main indirect effects of the COVID-19 pandemic on population health. The framework is presented in the next section. Based on this framework, a longlist of mechanisms and indicator areas was developed. For example, one pathway through which the COVID-19 pandemic affects population health is fear of getting infected or spreading infection. One specific underlying mechanism that can be discerned under this pathway involves stockpiling disinfectants and cleaners, as a result of which people are more exposed to dangerous substances and use too much disinfectant or apply disinfectants improperly, which leads to an increase in poisonings. Relevant indicator areas for monitoring this development include the occurrence of poisoning incidents and the occurrence of related morbidity and mortality. Another mechanism through which fear of infection can influence population health is inappropriate use of antibiotics. This can result in an increase in antimicrobial resistance. Relevant indicator areas for keeping track of this development include antibiotics prescription and consumption patterns and the emergence and spread of drug-resistant pathogens.

Member States are encouraged to select indicator areas that are relevant for their national situation and define specific indicators for those areas to be included in their (sub)national monitoring schemes. Data structures and indicator sets already in use can be built on, such as existing population health surveillance and health system performance assessment frameworks. When additional indicators are needed, the recommendation is to make use of existing, preferably internationally agreed, indicator definitions as much as possible. WHO has various indicator resources that can be used for reference, including:

y Global Reference List of 100 Core Health Indicators (World Health Organization (2018))

y WHO Global Health Observatory (Global Health Observatory (no date a))

y WHO Mortality Database (Global Health Observatory (no date b))

y WHO Global Health Expenditure Database (Global Health Expenditure Database (no date))

y WHO European Health Information Gateway (European Health Information Gateway (no date))

y Surveillance networks for infectious diseases: European Region measles and rubella surveillance (WHO Epi Data (no date)), global measles and rubella surveillance (World Health Organization (no date b)), polio surveillance (regional and global (Case Count (no date)), weekly epidemiological records (World Health Organization (no date c)).

In addition, useful indicators can also be found in other international organizations, such as the United Nations’ Sustainable Development Goal (SDG) indicators (United Nations (no date a), the OECD’s Health Care Quality and Outcomes (OECD (2018), and the European Commission’s European Core Health Indicators (European Commission (no date).

As a second element, this tool contains a set of important considerations for working with indicators to signal and keep track of the wider effects of the COVID-19 pandemic. These are aspects that need careful thought in order to reach an appropriate and policy-relevant set of indicators. First, in terms of the wider impacts of the COVID-19 pandemic on population health, several specific vulnerable groups can be identified. Given the fact that the pandemic has forcefully exposed the inequalities

INTRODUCTION 3

in our society (Stiglitz (2020)), it is important to apply an equity lens when monitoring the wider effects of COVID-19 to gain insight into who is most heavily affected by the outbreak, supporting targeted actions and deployment of resources where they are needed the most. Therefore, this tool contains an overview of groups that are likely to be affected the most by the wider effects of the COVID-19 pandemic, providing guidance for relevant disaggregations of indicators. Second, the tool describes important aspects related to data sources for monitoring the wider effects of the COVID-19 pandemic, including the potential use of alternative data sources (that is, data sources that are not commonly used for population health surveillance) and the desired frequency of data collection, which will differ for different kinds of indicators. Finally, as regards the wider effects COVID-19, the main goal will be to learn whether a certain indicator value has changed compared to the situation prior to the COVID-19 pandemic, that is, determine whether there is a disruption in the time trend. The tool explains the importance of setting an appropriate baseline and defining appropriate parameters for follow-up.

The third element of this tool is a list of core indicators. This list is based on the longlist of mechanisms and indicator areas, and contains a concise set of indicators that reflect the most important wider effects of the COVID-19 pandemic and are well-established and already being used regularly in many countries. Thus, in most cases, these indicators can easily be used as part of monitoring activities related to COVID-19. Therefore, the list of core indicators can serve as a practical starting point for Member States for monitoring the wider effects of the COVID-19 pandemic.

How the tool was developed

The conceptual framework for structuring the pathways of the wider effects of the COVID-19 pandemic was developed by first developing a draft framework based on the findings of a quick literature scan, including a first set of underlying mechanisms and indicator areas to populate the longlist. Next, the draft framework and the preliminary longlist were reviewed through an internal consultation among WHO experts at the regional and global level, as well as an external consultation (see the acknowledgement section at the beginning of this document). The experts suggested additional mechanisms through which population health can be affected and indicator areas that could be used to capture them, including additional literature to substantiate the suggested mechanisms. This feedback was processed in the next version of the tool. It is noted that, because the identified mechanisms and related developments in population health are often preliminary in nature, peer-reviewed research papers and official statistics are often not yet available to substantiate them. Therefore, other information sources (for example, press releases from international organizations, news items) are also used for reference in this tool, as are experiences from earlier crises.

The draft version of the tool, developed as described above, was subsequently released for public consultation. Eleven responses were submitted. The feedback derived from this public consultation was processed in this final version of the tool. Most notably, the indicator shortlist was added to the document to provide Member States with a concrete starting point for monitoring the wider effects of the COVID-19 pandemic.

When selecting relevant mechanisms and indicator areas, the primary focus has been on what was happening in and relevant for the European Region. Nevertheless, the framework for structuring


the pathways for the main effects of the COVID-19 pandemic on population health and many of the indicator areas presented in this tool will also be useful for other geographical regions.

It is noted that the information presented in this document represents the state of play in January 2021. Knowledge is growing and new insights about the wider effects of the COVID-19 pandemic will continue to emerge. WHO will monitor these emerging insights and update this document when necessary. The respondents to the public consultation also indicated that they would deem it useful if WHO would regularly update this document to reflect the latest state of play.

Conceptual framework

Five main pathways for the wider effects of the COVID-19 pandemic

The framework presented in this document focuses on the wider effects of the COVID-19 pandemic and, therefore, looks beyond the morbidity and mortality directly caused by COVID-19. In other words, it focuses on the effects on the general population rather than on COVID-19 patients (see Fig. 1). The framework discerns five main pathways through which the COVID-19 pandemic and the related containment measures can have an impact on general population health. First, the COVID-19 pandemic is affecting population health directly by causing fear of getting infected or a loved one getting infected, or fear of spreading the infection to others. Then, there are four main pathways through which the pandemic has an indirect effect on population health. The first of these (Pathway 2 in Fig. 1) is impaired health care for non-COVID-19 conditions. In our framework, these health care effects have been subdivided into effects on access, quality, and financial protection, reflecting the goals of universal health coverage (World Health Organization (no date d)). Next, COVID-19-related containment measures, such as quarantine and stay-at-home measures, can impact health directly (Pathway 3). Finally, containment measures impact population health by affecting health determinants. Here, we can distinguish between risk factors, such as tobacco use, alcohol use and diet (Pathway 4), and wider determinants of health (Pathway 5). The wider determinants are also called the social determinants of health. These are the conditions in which people are born, grow, live, work and age (Dahlgren and Whitehead (1991); World Health Organization (2021)). More details on the underlying mechanisms through which health is affected can be found in the longlist of mechanisms and indicator areas (Table 1). Next to these five pathways, the framework also contains a domain that covers the concrete health outcomes in terms of general health status and well-being, morbidity and mortality.

INTRODUCTION 5

Fig. 1. �Conceptual�framework�of�the�main�pathways�for�the�wider�effects�of�the�COVID-19 pandemic

Direct�effects�of�COVID-19�outbreak

Indirect�effects�of�COVID-19�outbreak

COVID-19 patients

General population*

General population*

Morbidity and mortality caused by COVID-19 and

its treatment

1. Fear of getting infected or spreading infection

2. Impaired healthcare for non-COVID-19 conditions Access, quality, financial protection

3. Direct effects of containment measures

4. Indirect effects of containment measures through risk factors

5. Indirect effects of containment measures through wider determinants of health

Short- and long-term health outcomes

Short- and long-term health outcomes:- General health

and well-being- Morbidity- Mortality

Population affected:

Pathway: Outcomes:

Scope of this WHO tool

* Several vulnerable groups (e.g. women, children, older people, prisoners, migrants, people experiencing homelessness) are likely to be affected more severely. Specific attention should be given to these groups while monitoring the wider effects of the COVID-19 pandemic on population health.

Health can be affected through different pathways in parallel

The framework presented in Fig. 1 is a simplified rendering of reality, aimed at illustrating the main pathways through which the COVID-19 pandemic can affect general population health. The framework does not reflect the fact that in practice health outcomes can be affected by various mechanisms in parallel, and that there can be interconnections between the different mechanisms. For example, mental health can be negatively affected by fear caused by the COVID-19 pandemic directly, by stress caused by containment measures such as working from home in combination with school closures, and by stress caused by (fear of) losing one’s job. The occurrence of vaccine-preventable diseases and measurements thereof can be influenced by COVID-19 containment measures, reduced resources for infectious disease surveillance, and changes in health-seeking behaviours. In addition, there can be interconnections between the different pathways. For example, containment measures may lead to a diminished availability of public transport, making it more difficult for people to seek care or for health care workers to get to work, thus affecting access to health care. Stress caused by the fear of getting infected may result in increased alcohol or tobacco use, thus affecting risk factors. For interpreting monitoring results, it is important to be aware of all the various pathways that may lead to changes in indicator values.


In the conceptual framework described in the previous paragraph, five main pathways through which the COVID-19 pandemic affects population health have been identified. In Table 1 below, for each of these pathways, the related underlying mechanisms are described, together with relevant indicator areas for keeping track of these developments. Next to the five pathways, the conceptual framework includes a domain to capture the actual effects of all the influences of the COVID-19 pandemic on population health. Table 2 lists relevant indicators for monitoring these health outcomes. Table 1 and 2 together form the longlist of underlying mechanisms and indicator areas.

Table 1. Mechanisms�underlying�the�main�pathways�of�the�wider�effects�of�the�COVID-19�pandemic and related indicator areas

Pathway Underlying mechanism Indicator areasNote: indicator areas for health outcomes, that is, measures capturing the actual effects on health status, can be found in Table 2


Fear causes elevated rates of stress and anxiety (Douglas et al. (2020); IASC (2020); OECD and European Union (2020); World Health Organization (no date e)).

• Psychological distress

Social stigma and discrimination against infected persons, health care professionals, people from certain ethnic communities and those who have travelled to affected countries (CDC (2020); World Health Organization (2020d)).

• Health literacy• Discrimination

An increase in poisonings due to:• Stockpiling of disinfectants and cleaners, resulting in

people being more exposed to dangerous substances. This applies to children in particular and this effect is enlarged by school closings;

• Using too much disinfectant or applying disinfectants improperly;

• Hazardous self-medication attempts.(Collie (no date); World Health Organization (no date f); Chang et al. (2020); Le Roux, Sinno-Tellier and Descatha (2020); Pan American Health Organization (2020)).• Misinformation on the alleged protective effect of alcohol

when ingested (Alekperova (2020); Farmer (2020); Regnum (2020); World Health Organization (2020b)).

• Poisoning incidents

1. Longlist of mechanisms and indicator areas

1. LONGLIST OF MECHANISMS AND INDICATOR AREAS 7


Inappropriate use of antibiotics during the pandemic contributes to a further increase in antimicrobial resistance (Arshad et al. (2020); World Health Organization (2020g); World Health Organization (no date g)).

• Antibiotics prescription and consumption patterns

• Emergence and spread of drug-resistant pathogens

People avoid seeking care for non-COVID-19 conditions (Czeisler et al. (2020); Douglas et al. (2020)), including long-term residential care (Cripps et al. (2020)). Next to fear of infection, people also avoid seeking care based on the assumption that care will not be available for them because the system is overwhelmed and because they were instructed by the government only to seek care when absolutely necessary. These mechanisms can be found under Pathway 2: Impaired health care for non-COVID-19 conditions (access).

See access-related indicator areas below

2. Impaired health care for non-COVID-19 conditions: access

Overarching mechanism: During the COVID-19 pandemic, there has been widespread disruption of regular health care services, leading to missed or postponed care for non-COVID-19 conditions. This disruption is caused both by developments that affect the supply of services and the demand for services. These underlying mechanisms are described in the table below. When health systems are overwhelmed, morbidity is exacerbated, disability intensifies, and both mortality from the outbreak (direct) and mortality from vaccine-preventable and treatable conditions (avoidable) increase (World Health Organization (2020l)). At the end of spring/beginning of summer 2020, about 40% of essential health care services had been at least partially disrupted in the European Region (World Health Organization (2020i)). Disruption of regular service delivery is seen throughout the health care system:• Primary health care (OECD and European Union (2020);

Rawaf et al. (2020))• Emergency care (Mulholland et al. (2020); OECD and

European Union (2020); Rausa et al. (2020))• Perinatal / maternity care (Coxon et al. (2020)), including

breastfeeding support (Vazquez-Vazquez et al. (2021))• Sexual and reproductive health care services (Endler et al.

(2020); IPPF (2020); Wenham (2020))• Mental health services (European Parliament (2020); OECD

and European Union (2020))• Drug services, including opioid substitution therapy and

clean drug-using equipment (EMCDDA (2020a); EMCDDA (2020b))

• Outpatient care (Mehrotra et al. (2020); OECD and European Union (2020); World Health Organization (2020j))

• Hospital care (Mulholland et al. (2020); Panteli (2020); RIVM (2020a))

• Preventive services: △ Vaccination (World Health Organization (no date h); Santoli et al. (2020)) △ Screening (Dinmohamed et al. (2020); World Health Organization (2020j))

• Rehabilitation (World Health Organization (2020j))• Palliative care (World Health Organization (2020j))• Surveillance (World Health Organization (2020e))• Social care (Cripps et al. (2020); Giebel et al. (2020))

• Unmet health care needs

• Waiting times• Coverage of health

care services for non-COVID-19 conditions (number of consultations, number of interventions)

• Patient-Reported Experience Measures (PREMs)



Developments�influencing�supply�(services):• Health care services are being confronted with increased

demand generated by the COVID-19 outbreak, which results in cancellation of non-urgent care not related to COVID-19 and repurposing of staff. See references above (overarching mechanism).

• As the COVID-19 pandemic progresses, staffing shortages will likely occur due to health care staff exposures, illness, or need to care for family members at home. This may result in a serious weakening of the health service provided and a much greater workload and stress for those left in the health care (CDC (2020); Sim (2020))

• The pandemic has led to an unprecedented adoption and use of telemedicine, which has helped preserve continuity of care (OECD and European Union (2020); Panteli (2020); Rawaf et al. (2020))

See indicator areas above (overarching mechanism). And:• Human resources for

health / workload• COVID-19 infections

and quarantines among health care staff

• Stress / well-being among health care staff

• Telemedicine consults

Developments�influencing�supply�(medical�products):• Containment measures such as lockdowns, shutting

countries down or reducing transport within and between them has affected the manufacturing, supply and distribution of medicines, leading to constraints in the global medicines supply chain. Demand also increased for some medicines used in patients with COVID-19. In addition, decreased manufacturing capacity and increased purchasing costs have contributed to shortages (European Medicines Agency (no date)).

• Severe and mounting disruption to the global supply of personal protective equipment (PPE) – caused by rising demand, panic buying, hoarding and misuse – is putting lives at risk from the new coronavirus and other infectious diseases (World Health Organization (2020k); Paton (2021)).

• Increased demand and problems in the supply chain also cause shortages of other critical medical equipment, such as ventilators and dialysis materials (Mahase (2020); Miller et al. (2020); Ranney, Griffeth and Jha (2020)).

• Supply of and demand for (essential) medicines

• Supply of and demand for PPE

• Supply of and demand for other critical medical equipment (ventilators, dialysis materials)

Developments�influencing�demand:• Governments instructed the population to relieve pressure

on services by staying away from primary care unless absolutely necessary (Rawaf et al. (2020)).

• Government or public transport lockdowns hinder access to health facilities (Douglas et al. (2020); World Health Organization (2020j)).

• People avoid seeking care because they assume care will not be available for them / the doctor will be too busy (Rubin (2020); Sarwari and Goode (2020)).

Another important reason why patients avoid seeking care is fear of infection. This mechanism can be found under Pathway 1: Fear of getting infected or spreading infection.

See indicator areas above (overarching mechanism)



2. Impaired health care for non-COVID-19 conditions: quality

Balancing care provision for COVID-19 patients and catching up with delayed care needs for non-COVID-19 patients increases the pressure on health care systems to such an extent that quality of service delivery is compromised (Coma et al. (2020); World Health Organization (2020l)).

• Health care quality in various settings (for example, primary care, hospital care, acute care)

• Patient safety / adverse effects

• Average length of stay in hospital for (specific) non-COVID-19 conditions

• Patient-Reported Experience Measures (PREMs)

• Adherence to medical guidelines

• Timeliness of quality control measures

2. Impaired health care for non-COVID-19 conditions: financial�protection

The economic recession that has arisen due to the consequences of nationwide stay-at-home orders and business closures may result in diminished government spending on health and social protection (Douglas et al. (2020)). This was the case during the previous financial crisis, when public spending on health per person fell or slowed in many countries between 2007 and 2012 (Thomson et al. (2014))

• Public spending on health (by function, provision, illness)

• Public spending on social services

Reduced government spending on health may lead to increased out-of-pocket payments for health. In addition, the economic downturn impacts household financial security and the capacity to pay for health care. These developments may result in increased financial barriers to access to health services, unmet needs, and increased financial hardship (Thomson, Cylus and Evetovits (2019)).

• Out-of-pocket payments

• Catastrophic and impoverishing health spending

• Unmet needs


Essential quarantine, isolation and social distancing interventions risk serious social and psychological harm, and can lead to an acute, severe sense of social isolation and loneliness with potentially serious mental and physical health consequences (Douglas et al. (2020); Hwang et al. (2020)).

• Household size• Social support• Loneliness

Measures such as stay-at-home orders and school closings can have positive effects on family life (for example, parents having more time because they do not have to commute to work, more opportunities to do things together as a family), but they can also cause stress and mental health problems (Douglas et al. (2020); Power (2020)).

• Psychological distress• Work-life balance• Time spent on unpaid

domestic and care work

• Time spent outside / time for leisure activities



Working at home can affect mental health negatively (for example, through feelings of isolation and fatigue), but it can also have positive effects (for example, through decreased stress) (Franklin (2020); Oakman et al. (2020)). An increase in musculoskeletal complaints has also been reported (Franklin (2020); NOS (2020a)).

• Psychological distress• Home working

conditions

Measures such as stay-at-home orders and school closings have led to an increase in domestic violence, including child maltreatment and intimate partner violence, especially against women (OECD (2020a); World Health Organization (2020a)).

• Interpersonal violence (intimate partner violence, child maltreatment, elderly abuse)

People relying on informal care may experience an increase in support provided, for example, shopping assistance, reflecting the rise of volunteering and community action that was sparked by the pandemic (Evandrou et al. (2020)). On the other hand, there have been disruptions in the provision of formal social care (see Pathway 2, access).

• (Unmet) need for informal care

• Social support

Measures such as increased promotion of hand hygiene and physical distancing do not only prevent the spread of COVID-19, but also of other infectious diseases (NOS (2020b); Olsen et al. (2020)).

• Adherence to containment measures such as hygiene and physical distancing measures


Stress related to the COVID-19 pandemic appears to affect smokers in different ways, with some smokers increasing their smoking and others decreasing it. While boredom and restrictions in movement might have stimulated smoking, the threat of contracting COVID-19 (see Pathway 1) and becoming severely ill might have motivated others to improve their health by quitting smoking (Bommelé et al. (2020); Edmond (2020); Yach (2020)).

• Tobacco use

On the one hand, alcohol use can go up as a result of an increase in psychological distress, especially in specific subgroups (Sallie et al. (2020)), and on the other hand, alcohol use may go down due to decreased physical availability of and financial means to procure alcohol, especially in the earlier phases of the pandemic (Rehm et al. (2020)).

• Alcohol use

Containment measures such as stay-at-home orders and closures of places such as gyms, stadiums, pools, parks, and playgrounds have limited options for people to be physically active. This can lead to longer screen time, irregular sleep patterns and worse diets, resulting in weight gain and loss of physical fitness (UN DESA (2020)). On the other hand, taking a walk or a bike ride might be one of the few options for leisure left, and due to school closures, children may have more time to play outside. Fear of infection (see Pathway 1) may also motivate people to improve their health to be better protected against the virus, and to walk or bike instead of using public transport (Ding et al. (2020)). Studies on the effects of the COVID-19 pandemic on physical activity show mixed results (Huber et al. (2020); RIVM (2020b); Schmidt et al. (2020); Tornaghi et al. (2020)).

• Physical activity• Overweight/obesity• Hypertension• High cholesterol



Stay-at-home orders and stockpiling food, due to the restriction in grocery shopping, influence food patterns. In addition, the interruption of the work routine could result in boredom, which in turn is associated with a greater energy intake. Stress caused by the pandemic can lead to overeating, especially of so-called comfort foods that are high in sugar. Unhealthy temptations at home, more free time and less social control can be other factors contributing to less healthy food intake. On the other hand, dietary patterns can also change for the better (for example, to boost one’s immune system (see Pathway 1), due to having fewer temptations at work during lockdown or more time to prepare healthy meals) (Beard-Knowland (2020); Di Renzo et al. (2020); Wageningen University & Research (2020)).

• Diet• Overweight/obesity• Hypertension• High cholesterol

Changes in drug consumption patterns during the initial phases of the COVID-19 pandemic in Europe have been noted, mostly resulting from the implementation of confinement and social distancing measures. The use of cocaine and MDMA decreased, and local shortages of heroin were reported, resulting in an increase in the use of replacement substances and attempts to access opioid substitution treatment services in some countries (see Pathway 2, access). A more mixed picture is reported for cannabis, with some occasional users stopping or reducing its use, while more frequent users may have increased consumption, mainly to relieve boredom and anxiety (European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) (2020a); EMCDDA (2020)).

• Illicit drug use


The swift and massive shock of the coronavirus pandemic and the shutdown measures implemented to contain it have plunged the global economy into a severe contraction (The World Bank (2020)). An economic crisis affects population health through two pathways: reductions in household financial security and reductions in government resources. Both can lead to changes in levels of stress, health-related behaviours and access to health services. Recessions can also have a positive impact on health, mainly due to reductions in road traffic accidents and increases in health-enhancing behaviours, such as smoking less or drinking less, even though risk behaviours such as alcohol consumption and smoking may increase among people who binge-drink or are unemployed (see Pathway 4). (Thomson et al. (2015)).

• Income / (at risk of) poverty

• Public spending on essential services

Compared to December 2019, unemployment rose by 1.951 million in the EU in December 2020 (Eurostat (2021a)). Unemployment can affect people’s health through having less income (see cell above), but it can also impact health directly. Evidence from previous economic crises shows that unemployment and fear of losing one’s job are associated with several health problems, most notably mental and behavioural disorders, including suicide (Thomson et al. (2015)).

• Unemployment• Workers on flexible

contracts / informal workers



Education and health and well-being are intrinsically linked. The evidence behind the importance of education as a determinant of health is amongst the most compelling (The Lancet Public Health (2020)). Most educational institutions around the world cancelled in-person instruction and moved to remote learning and teaching during the pandemic to contain the spread of COVID-19. A study carried out by the European Commission’s Joint Research Centre shows that estimates for a few selected EU countries consistently indicate that, on average, students will suffer a learning loss. It is also suggested that COVID-19 will not affect students equally, will negatively influence both cognitive and non-cognitive skill acquisition, and may have important long-term and short-term consequences (European Commission, Joint Research Centre (2020)).

• Education• Childhood

development

The lockdown and related measures implemented by many European countries to stop the spread of COVID-19 have led to a sudden decrease in economic activities, including a drop in road transport in many cities. Concentrations of nitrogen dioxide (NO2) — a pollutant mainly emitted by road transport — have decreased in many European cities where lockdown measures have been implemented. Although a decrease in concentrations of fine particulate matter (PM2.5) may also be expected, a consistent reduction cannot yet be seen across European cities. This is likely due to the fact that the main sources of this pollutant are more varied. Exposure to air pollution can lead to adverse health effects, including respiratory and cardiovascular diseases (EEA (2020)).

• Air quality• Transport behaviour


Table 2. Indicator�areas�for�monitoring�health�outcomes

Health outcomes Indicator areas

General health and well-being Self-perceived (mental) health

Quality of life

Well-being

Sleep

Patient-Reported Outcome Measures (PROMs)

Morbidity Occurrence of chronic diseases

Occurrence of mental disorders

Occurrence of (vaccine-preventable) infectious diseases

Occurrence of non-fatal injuries

Mortality All-cause mortality

Excess mortality

Mortality from chronic diseases

Mortality from infectious diseases other than COVID-19

Fatal injuries (including suicide)

Maternal mortality

Neonatal mortality

Under-five mortality

Avoidable mortality1

1 Avoidable mortality can be split up into amenable and preventable mortality. A death is amenable if, in the light of medical knowledge and technology, at the time of death, all or most deaths from that cause could be avoided through optimal quality health care. A death is preventable if, in the light of understanding of the determinants of health at the time of death, all or most deaths from that cause could be avoided by public health interventions in the broadest sense (Eurostat, https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Amenable_and_preventable_deaths_statistics&direction=next&oldid=337528).

https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Amenable_and_preventable_deaths_statistics&direction=next&oldid=337528

https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Amenable_and_preventable_deaths_statistics&direction=next&oldid=337528


2.1. Indicator disaggregations for identifying health inequalities and vulnerable groups

The wider effects of the COVID-19 pandemic are having an impact across the whole of society, but some groups are more heavily affected than others. It is important to take these inequalities into account when monitoring the wider effects to gain insight into who is impacted the most by the outbreak, supporting targeted actions and deployment of resources where they are needed most. Basic disaggregations of indicators by age groups and gender are highly relevant in this respect, but other vulnerable groups can be discerned as well, demanding additional, more sophisticated stratifications of the data. The most relevant disaggregations are listed and explained below. Several of these groups are not only more vulnerable to the secondary effects of the pandemic, but also at increased risk of being exposed to the virus and getting infected, for example, because they live in cramped housing conditions or have a job that cannot be done from home. This aspect is not taken into account here, as the focus of this tool is on the wider effects of the pandemic.

It should be noted that certain vulnerable groups may be underrepresented in or excluded from regular data collections used for population health monitoring. This implies that to obtain a good picture of the impact of the COVID-19 pandemic on these subpopulations, additional targeted data collection efforts may be needed (for example, for people experiencing homelessness, prisoners, older people in institutionalized care, refugees).

Age groups

Older people – Since the virus has largely affected the elderly, lockdown measures for older individuals have been stricter, increasing the risk for social isolation. In addition, older people are more likely to live alone and less likely to use digital tools and online communications, adding to this risk. Stricter lockdowns in combination with higher threat of illness and loss of social support may result in higher levels of anxiety and depression among the older population (Douglas et al. (2020); Martins Van Jaarsveld (2020)).

Children – School closures, physical distancing and confinement increase the risk of poor nutrition among children, their exposure to domestic violence, increase their anxiety and stress, and reduce access to vital family and care services, such as immunization, school feeding, and mental health and psychosocial support. Furthermore, increased unsupervised online internet use has magnified issues around sexual exploitation and cyberbullying (OECD (2020a); UNICEF (2020)).

2. Important considerations for monitoring the wider effects of COVID-19

2. IMPORTANT CONSIDERATIONS FOR MONITORING THE WIDER EFFECTS OF COVID-19 15

Young adults – The mental health impact of the COVID-19 pandemic has been significantly greater in young adults than the rest of the adult population and is associated with increased loneliness and lower positive mood (Jia et al. (2020); RIVM (2021)). Moreover, young people are disproportionately affected by the COVID-19 crisis, with multiple shocks, including disruption to education and training, employment and income losses, and greater difficulties in finding a job (ILO (2020)).

Gender

Women – Women are more at risk in an economic downturn because they are more often engaged in short-term, part-time, or informal employment. The closure of schools to control COVID-19 might have a differential effect on women, who provide most of the informal care within families, with the consequence of limiting their work and economic opportunities or causing increased levels of stress if homeschooling and working from home need to be combined. Women may be less likely than men to have power in decision-making related to the outbreak, and consequently, their sexual and reproductive health needs may go unmet. Women are at increased risk of intimate partner violence during lockdown measures and during the recovery phase due to potential cuts in services (United Nations Europe and Central Asia Issue-Based Coalition (no date); Douglas et al. (2020); United Nations (2020); Wenham (2020); World Health Organization and Human Reproduction Programme (2020)).

Men – Evidence from earlier economic crises suggests that men are at increased risk of suicide in times of economic downturn (Chang et al. (2013); Coope et al. (2014)).

Socioeconomic status (income, education, occupation)

People on low income – Effects of the pandemic will be particularly severe as they already tend to have poorer health and are more likely to be in insecure work without financial reserves. Such financial uncertainty disproportionately harms the mental health of those in low socioeconomic groups and exacerbates their stress (Douglas et al. (2020); Patel et al. (2020)).

Workers� on� precarious� contracts,� informal�workers� or� self-employed – High risk of adverse effects from loss of work and lack of income. Although the COVID-19 pandemic appears to disproportionately affect those in informal employment, they often receive less government support than the formally employed (Douglas et al. (2020); Webb, McQuaid and Rand (2020)).

Place of residence / living situation

People living in more deprived areas – Affected by multiple factors that put them at increased risk of being impacted by the wider effects of the COVID-19 pandemic, such as low income, poor/crowded housing, precarious work, migrant status, and barriers to accessing health services (Bambra et al. (2020); Patel et al. (2020)).

People living alone – At increased risk of isolation and loneliness during self-isolation and quarantine (Bu, Steptoe and Fancourt (2020); Groarke et al. (2020)).


People living in prisons/detention centres – People in prisons and other places of detention are already deprived of their liberty and may react differently to having further restrictive measures imposed upon them. Children in detention centres are particularly vulnerable to the negative effects of restrictions on activities and social/family contacts. Control measures restricting social interaction may aggravate behavioural problems (Savage (2020); World Health Organization (2020f); World Health Organization (2020c)).

People�living�in�residential�care�facilities – At increased risk of isolation and loneliness due to lockdown measures completely or severely limiting social interaction with other residents and access for visitors, including family and informal caregivers (Simard and Volicer (2020); Verbeek et al. (2020)).

People experiencing homelessness – May be affected by disrupted support services, as organizations that typically provide assistance for those experiencing homelessness appear to be struggling to meet the immediate needs of this group in light of the COVID-19 outbreak (Clark-Ginsberg, Hunter and Henwood (2020); Douglas et al. (2020)).

People with a chronic condition or disability

People with chronic conditions – Affected by disrupted care and support services ((Douglas et al. (2020)), see Table 1).

People�with� a disability – People with disabilities are facing isolation and exclusion as social support services and networks – including personal assistance like caregivers – are disrupted. They may have difficulties carrying out daily activities such as showering and using the restroom without assistance (Douglas et al. (2020); Reliefweb (2020)).

Refugee or migrant status

Migrants – May experience health vulnerabilities due to socioeconomic status, being in crowded or otherwise suboptimal environments, restriction to eligibility or access to health and other services, or cultural-linguistic barriers to health information (IOM (no date)). Migrants also have an unfavourable position on the labour market, among other reasons, because they are strongly overrepresented in the sectors most affected by the pandemic and because of their generally less stable employment conditions. At risk of stigma and discrimination due to misinformation regarding the role of immigrants in the spread of the virus (OECD (2020b); World Health Organization (2020h)).

Refugees – People in refugee camps suffer cramped living conditions, weak or non-existent health care systems, and lack of access to clean water (USGLC (2020)). They may experience limited access to health care, which some may even avoid out of fear of deportation. This situation is aggravated by language barriers. Overwhelmed medical services in refugee camps could lead to an increase in mortality from infectious diseases (other than COVID-19) and socioeconomic hardship can exacerbate mental health problems (Alemi et al. (2020)).

2. IMPORTANT CONSIDERATIONS FOR MONITORING THE WIDER EFFECTS OF COVID-19 17

The need to look beyond simple disaggregations

The most important stratifiers for identifying those who are the most vulnerable to the wider effects of the COVID-19 pandemic have been listed above. It should be noted, however, that in order to identify the most disadvantaged groups, it may be necessary to combine several of these disaggregating factors. For example, all children will be impacted by school closures, but the poorest children are the least likely to benefit from the widespread digitalization that was deployed to mitigate education loss, because they are the least likely to live in good home-learning environments with internet connection (OECD (2020a)). And while all people living in care homes are at increased risk of isolation and loneliness due to lockdown measures, the impacts will be especially burdensome for residents with cognitive impairment and dementia (Simard and Volicer (2020)). These examples illustrate the need to look beyond simple disaggregations to get a good picture of the inequalities related to the COVID-19 pandemic.

2.2. Data sources

As can be seen in Table 1, the wider effects of the COVID-19 pandemic are very diverse in nature. This implies that for a comprehensive monitoring of these effects, data from many different sources are needed, including, for example, cause-of-death statistics, surveys, disease registries, data from health care services, police records, social benefits data, and sales statistics. In addition to these more commonly used data sources, alternative sources can be considered to meet the information needs for monitoring the wider effects. For example, data on usage of mental health helplines could be a good way of gaining insight into the burden of mental health problems. Helpline usage data can also be a useful source of information on the occurrence of interpersonal violence, as can shelter utilization records and police crime data. Data from consumer panels can provide insight into risk factors such as alcohol and tobacco use and diet. Such alternative data sources can serve as a pragmatic proxy when the commonly used data sources are not available or cannot provide data with the desired frequency (see below), but they can also complement regular sources and thus contribute to a richer evidence base for policy-making. Big data, such as data from online platforms, social media and apps, could be a useful complementary source of information about how people respond to the pandemic and the measures taken to contain it. If quantitative data are lacking or insufficient, using expert opinion as a source of information could also be considered.

Another aspect to take into account when looking for suitable data sources is the desired frequency of data collection and reporting. Some of the wider effects of the COVID-19 pandemic will emerge quickly, and related indicator values may change rapidly. This implies that regular data collection routines may not be flexible and timely enough to accurately capture these developments. For example, containment measures can have an immediate impact on risk factors like tobacco use and physical activity. However, data on these risk factors are usually collected once a year or once every few years. Therefore, relying on the regular survey schedule will not suffice and including additional (online and/or telephonic) waves/modules in the schedule could be considered to ensure timely data. Indeed, several countries have set up dedicated survey schemes to capture how COVID-19 and the measures being used to prevent its spread are affecting the physical, mental,


and social well-being of people.2 In some countries, regular interview surveys are being conducted on a continuous basis. If this is the case, preliminary data could be reported on a quarterly basis, for example. Likewise, preliminary data from various registries in which data are being collected on a continuous basis could be reported on a monthly or quarterly basis to provide insight into quickly changing indicator values. However, caution should be exercised when communicating about such data because time lags can occur between the timing of events and their recording in registries, and often it will not have yet been possible to carry out all the required quality checks. Therefore, it should be stressed that these data can provide a preliminary indication of how the situation is developing, but they are not yet complete and fully validated. Finally, alternative data sources such as use of helplines or police records can be relied upon to obtain more frequent data than regular sources would be able to provide (see above).

2.3. Working with time trends

When looking at the wider effects COVID-19, the main goal will be to learn whether a certain indicator value has changed compared to the situation prior to the COVID-19 pandemic, that is, determine whether there is a disruption in the time trend. This implies that, where possible, a baseline needs to be set. For example, a relevant indicator could be the number of life-saving medical interventions performed. To determine to what extent the indicator values for the current situation are divergent from what is to be expected under normal circumstances, the values can be compared, for example, to the average value for the same month for several preceding years. The most appropriate baseline may differ per indicator. In addition, the required granularity and duration for follow-up needs to be defined for each indicator, considering the time lag between the concerned determinant and its effects and what is necessary for optimally informing policy-making. For example, missed urgent care for non-COVID-19 conditions is likely to result in an increase in morbidity and mortality in the short term. Capturing the relevant trends here and providing timely evidence for policy-making will require indicators to be measured at relatively short intervals (for example, once a month). However, it may take many years for the effects of changes in risk factors or vaccination rates to become visible in morbidity and mortality data. To capture these effects, longer-term follow-up is necessary, and a regular reporting frequency of once a year will suffice. On the other hand, as addressed in the previous paragraph, the actual changes in underlying risk factors (for example, tobacco use, alcohol use) are expected to occur quickly and will be measurable in the short term, which indicates that shorter periods of follow-up are again necessary for capturing these changes.

2 For example, Public Health Wales is conducting weekly interviews with hundreds of people aged 18 or over across Wales, and in December 2020, Belgian Public Health Institute Sciensano was conducting a fifth online COVID-19 health interview survey since the start of the pandemic.

https://phw.nhs.wales/topics/latest-information-on-novel-coronavirus-covid-19/how-are-you-doing/how-are-we-doing-in-wales-reports/

https://www.sciensano.be/en/press-corner/participate-5th-covid-19-health-survey:/www.sciensano.be/en/press-corner/participate-5th-covid-19-health-survey

https://www.sciensano.be/en/press-corner/participate-5th-covid-19-health-survey:/www.sciensano.be/en/press-corner/participate-5th-covid-19-health-survey

3. LIST OF CORE INDICATORS 19

Based on the indicator areas in Tables 1 and 2, a concise set of indicators that are well-established and already in regular use in many countries was developed to reflect the most important wider effects of the COVID-19 pandemic across the different pathways (see Fig. 1). This list of core indicators is presented in Table 3. It can serve as a practical starting point for Member States for monitoring the wider effects of the COVID-19 pandemic. Table 3 for each indicator lists the indicator name, a metadata source where more information can be found on, for example, the precise indicator definition and calculation, the relevant disaggregations (see Section 2.1), and the recommended frequency of data collection and data source type (see Section 2.2). Information about the recommended baseline for comparison changes over time is also provided (see Section 2.3). It is noted that in practice, not all the recommendations in the table may be feasible. For example, it may not be possible to disaggregate the data according to all the recommended stratifiers, or only an alternative type of data source may be available that is different from the recommended type, or only a shorter time trend may be available for calculating the baseline value. However, this does not mean that the indicator will not be useful and should not be used, only that one should be aware of such limitations and take them into account when interpreting and working with the indicator values.

3. List of core indicators


Table 3. List�of�core�indicators�

For all the indicators in the list, the recommended baseline is the average value for the same period (that is, month, quarter, or year) over the 4 years prior to the onset of the pandemic (2016–2019).

Pathway Indicator Metadata Relevant disaggregations3

Recommended data source type

Recommended frequency


Psychological distress

Currently not included in regular international data collections. However, well-established tools do exist; see, for example, MHI-54 or SF-12, both based on the RAND Short Form Survey (SF-36) (RAND (no date)). It is recommended that Member States use existing national tools, if available.

• Age• Gender• Socioeconomic

status (SES)• Refugee or

migrant status

Population-based health survey

• If continuous data collection: report on a quarterly basis

• If no continuous data collection: consider collecting and reporting on survey data twice a year

• Otherwise: annual survey schedule

Consumption of antimicrobial medicines (with relative use of Access and Watch group antibiotics5)

WHO Regional Office for Europe Antimicrobial Medicines Consumption (AMC) Network: AMC data 2011–2017 (World Health Organization (2020m))

- Import / wholesaler data or health insurance data

• If health insurance registry available based on continuously collected data: report on a monthly or quarterly basis

• Otherwise: annual reporting

2. Impaired health care for non-COVID-19 conditions: access

Outpatient contacts for non-COVID-19-related conditions

Global Reference List of 100 Core Health Indicators (World Health Organization (2018))Note: the name of the relevant indicator in the Global Reference list is Outpatient service utilization (Also: inpatient admissions and surgical volume). This indicator would need to be broken down into outpatient contacts for COVID-19 and for other conditions. This requires data on service utilization by diagnosis (ICD6).

• Age• Gender

Health care facility registers or health insurance data

• If health care facility registry available based on continuously collected data: report on a monthly or quarterly basis


3 Here we focus on those stratifications that can be obtained from the primary data source directly. For example, looking at the indicator on outpatient contacts for non-COVID-19-related conditions, it could also be relevant to look at SES and refugee or migrant status. In most Member States, however, obtaining such disaggregations would require linkage of health care facility data with other data sources. Therefore, for the purpose of this document, we consider this to fall outside the scope of regular population health monitoring. Nevertheless, such linkage exercise could be performed for more in-depth analyses of the data, if countries want more comprehensive information on potential health inequalities.

4 MHI-5 was used in the first wave of the European Health Interview Survey (EHIS) (but not in later waves): How much of the time, during the past 4 weeks: Have you been very nervous? Have you felt so down in the dumps that nothing could cheer you up? Have you felt calm and peaceful? Have you felt downhearted and depressed? Have you been happy? The five response categories were: 1. All of the time; 2. Most of the time; 3. Some of the time; 4. A little of the time; 5. None of the time. See https://www.volksgezondheidenzorg.info/sites/default/files/38._psychological_distress_20120525.pdf.

5 For an explanation of Access and Watch group antibiotics, see https://www.who.int/medicines/news/2019/WHO_releases2019AWaRe_classification_antibiotics/en/.

6 International Classification of Diseases (https://www.who.int/standards/classifications/classification-of-diseases).

https://www.volksgezondheidenzorg.info/sites/default/files/38._psychological_distress_20120525.pdf

https://www.volksgezondheidenzorg.info/sites/default/files/38._psychological_distress_20120525.pdf

https://www.who.int/medicines/news/2019/WHO_releases2019AWaRe_classification_antibiotics/en/

https://www.who.int/medicines/news/2019/WHO_releases2019AWaRe_classification_antibiotics/en/

https://www.who.int/standards/classifications/classification-of-diseases





Hospital admissions for non-COVID-19-related conditions

See Outpatient contacts for non-COVID-19-related conditions

• Age• Gender

Health care facility registers or health insurance data

• If health care facility registry available based on continuously collected data: report on a monthly or quarterly basis


Immunization coverage rate by vaccine for each vaccine in the national programme [SDG 3.b.1]

Global Reference List of 100 Core Health Indicators (World Health Organization (2018))

• Gender Immunization registries

• If immunization registry available based on continuously collected data: report on a monthly or quarterly basis


Self-reported unmet needs for medical examination by reason

EU-SILC (Eurostat (no date)) • Age• Gender• SES• Refugee or

migrant status• People with

a chronic condition or disability





2. Impaired health care for non-COVID-19 conditions: quality�of�care

Perioperative mortality rate


• Age• Gender

Health care quality registers

• If health care quality registry available based on continuously collected data: report on a monthly or quarterly basis


2. Impaired health care for non-COVID-19 conditions: financial�protection

Proportion of the population with large household expenditure on health as a share of total household expenditure or income [SDG 3.8.2]Note: complementary regional indicators are used by WHO7


• SES Household survey




7 Regional indicators are used to complement SDG 3.8.2 in order to improve relevance to the European context and provide actionable evidence for policy. For recent analysis of catastrophic and impoverishing health spending across a wide range of Member States in the European Region, see https://www.euro.who.int/en/health-topics/Health-systems/health-systems-financing/universal-health-coverage-financial-protection

https://www.euro.who.int/en/health-topics/Health-systems/health-systems-financing/universal-health-coverage-financial-protection






Overall perceived social support (close people to count on, concern shown by other people, practical help from neighbours if needed)

European Health Interview Survey (EHIS) – social environment (Eurostat (no date))

• Age• Gender• SES• Refugee or







Intimate partner violence prevalence [SDG 5.2.1]


• Age• Gender• SES

• Population-based surveys focused on partner violence or population-based surveys with special module on partner violence

• Alternative sources such as data from police records, shelters, helplines.

• If based on regular population-based survey with continuous data collection: report on a quarterly basis

• If based on special survey: consider collecting and reporting on survey data twice a year

• If alternative sources available: monthly or quarterly reporting



Age-standardized prevalence of current tobacco use among persons aged 15+ years







Prevalence of insufficient physical activity

Global Health Observatory (no date c)











Unemployment rate [SDG 8.5.2]

SDG Indicators: Metadata repository (United Nations (no date b))




Administrative records such as employment office records and social insurance statistics8.

• Monthly or quarterly

Health outcomes

Self-perceived health

EU-SILC (Eurostat (no date)) • Age• Gender• SES• Refugee or



• Place of residence





Prevalence of depression

European Health Interview Survey (EHIS) – Self-reported chronic morbidity (Eurostat (no date))




• Place of residence





Suicide mortality rate [SDG 3.4.2]


• Age• Gender• Place of

residence

Civil registration and vital statistics system

Annually

Excess mortality

Excess mortality – statistics (Eurostat (2021b))

• Age• Gender

Civil registration and vital statistics system

Monthly

8 The statistics derived from these administrative records refer to a narrower concept (“registered unemployment”) than the statistics based on labour force surveys (ILO (no date)). However, they are the preferred source here, as they can provide more frequent updates.


Alekperova J (2020). Why are people more poisoned by alcohol during the quarantine period? Media.Az spoke with the country’s chief toxicologist. Media.az (https://media.az/society/1067776187/pod-vliyaniem-intoksikacii-chelovek-mozhet-prosnutsya-slepym-toksikolog-rasskazal-o-kolichestve-otravleniy, accessed 17 July 2020).

Alemi Q et al. (2020). Refugees and COVID-19: achieving a comprehensive public health response. Bulletin of the World Health Organization, 98(8), pp. 510-510A. doi: 10.2471/BLT.20.271080.

Arshad M et al. (2020). Covid-19, misinformation, and antimicrobial resistance. BMJ, p. m4501. doi: 10.1136/bmj.m4501.

Bambra C et al. (2020). The COVID-19 pandemic and health inequalities. Journal of Epidemiology and Community Health, p. jech-2020-214401. doi: 10.1136/jech-2020-214401.

Beard-Knowland T (2020). The impact of COVID-19 on how we eat. Ipsos (https://www.ipsos.com/sites/default/files/ct/publication/documents/2020-05/impact_of_covid-19_on_how_we_eat_ipsos_sia.pdf, accessed 4 February 2021).

Bommelé J et al. (2020). The double-edged relationship between COVID-19 stress and smoking: Implications for smoking cessation. Tobacco Induced Diseases, 18(July). doi: 10.18332/tid/125580.

Bu F, Steptoe A, Fancourt D (2020). Who is lonely in lockdown? Cross-cohort analyses of predictors of loneliness before and during the COVID-19 pandemic. Public Health, 186, pp. 31–34. doi: 10.1016/j.puhe.2020.06.036.

Case Count (no date). Geneva: World Health Organization (https://extranet.who.int/polis/public/CaseCount.aspx, accessed 28 March 2021.

CDC (2020). Reducing Stigma. Atlanta: Centers for Disease Control and Prevention; 2020 (https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/reducing-stigma.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fsymptoms-testing%2Freducing-stigma.html, accessed 22 July 2020).

Chang A et al. (2020). Cleaning and Disinfectant Chemical Exposures and Temporal Associations with COVID-19 — National Poison Data System, United States, January 1, 2020–March 31, 2020. Morbidity and Mortality Weekly Report, 69(16), pp. 496–498. doi: 10.15585/mmwr.mm6916e1.

References

https://media.az/society/1067776187/pod-vliyaniem-intoksikacii-chelovek-mozhet-prosnutsya-slepym-toksikolog-rasskazal-o-kolichestve-otravleniy



https://www.ipsos.com/sites/default/files/ct/publication/documents/2020-05/impact_of_covid-19_on_how_we_eat_ipsos_sia.pdf



https://extranet.who.int/polis/public/CaseCount.aspx

https://extranet.who.int/polis/public/CaseCount.aspx

https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/reducing-stigma.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fsymptoms-testing%2Freducing-stigma.html



REFERENCES 25

Chang SS et al. (2013). Impact of 2008 global economic crisis on suicide: time trend study in 54 countries. BMJ, 347(sep17 1), pp. f5239–f5239. doi: 10.1136/bmj.f5239.

Clark-Ginsberg A, Hunter S, Henwood B (2020). Emergency Homeless Services During the COVID-19 Crisis. The RAND blog, 7 April (https://www.rand.org/blog/2020/04/emergency-homeless-services-during-the-covid-19-crisis.html, accessed 10 February 2021).

Collie M (no date). Accidental poisonings from cleaning supplies on the rise during COVID-19 outbreak. Globalnews.ca (https://globalnews.ca/news/6905692/coronavirus-cleaning-poisonings, accessed 20 July 2020).

Coma E et al. (2020). Primary care in the time of COVID-19: monitoring the effect of the pandemic and the lockdown measures on 34 quality of care indicators calculated for 288 primary care practices covering about 6 million people in Catalonia. BMC Family Practice, 21(1), p. 208. doi: 10.1186/s12875-020-01278-8.

Coope C et al. (2014). Suicide and the 2008 economic recession: Who is most at risk? Trends in suicide rates in England and Wales 2001–2011. Social Science & Medicine, 117, pp. 76–85. doi: 10.1016/j.socscimed.2014.07.024.

Coxon K et al. (2020). The impact of the coronavirus (COVID-19) pandemic on maternity care in Europe. Midwifery, 88, p. 102779. doi: 10.1016/j.midw.2020.102779.

Cripps J et al. (2020). COVID-19 report. Impact on Social Care. Institute and Faculty of Actuaries (https://www.actuaries.org.uk/system/files/field/document/Impact%20of%20COVID-19%20on%20social%20care%20-%20Final%20Paper.pdf, accessed 5 February 2021).

Czeisler MÉ et al. (2020). Delay or Avoidance of Medical Care Because of COVID-19–Related Concerns — United States, June 2020. Morbidity and Mortality Weekly Report, 69(36), pp. 1250–1257. doi: 10.15585/mmwr.mm6936a4.

Dahlgren G, Whitehead M (1991). Policies and strategies to promote social equity in health. Background document to WHO – Strategy paper for Europe. Institute for Future Studies (https://core.ac.uk/download/pdf/6472456.pdf, accessed 22 June 2020).

Di Renzo L et al. (2020). Eating habits and lifestyle changes during COVID-19 lockdown: an Italian survey. Journal of Translational Medicine, 18(1), p. 229. doi: 10.1186/s12967-020-02399-5.

Ding D et al. (2020). Is the COVID-19 lockdown nudging people to be more active: a big data analysis. British Journal of Sports Medicine, 54(20), pp. 1183–1184. doi: 10.1136/bjsports-2020-102575.

Dinmohamed AG et al. (2020). The impact of the temporary suspension of national cancer screening programmes due to the COVID-19 epidemic on the diagnosis of breast and colorectal cancer in the Netherlands. Journal of Hematology & Oncology, 13(1), p. 147. doi: 10.1186/s13045-020-00984-1.

https://www.rand.org/blog/2020/04/emergency-homeless-services-during-the-covid-19-crisis.html

https://www.rand.org/blog/2020/04/emergency-homeless-services-during-the-covid-19-crisis.html

https://globalnews.ca/news/6905692/coronavirus-cleaning-poisonings

https://globalnews.ca/news/6905692/coronavirus-cleaning-poisonings

https://www.actuaries.org.uk/system/files/field/document/Impact%20of%20COVID-19%20on%20social%20care%20-%20Final%20Paper.pdf

https://www.actuaries.org.uk/system/files/field/document/Impact%20of%20COVID-19%20on%20social%20care%20-%20Final%20Paper.pdf

https://core.ac.uk/download/pdf/6472456.pdf

https://core.ac.uk/download/pdf/6472456.pdf


Douglas M et al. (2020). Mitigating the wider health effects of covid-19 pandemic response. BMJ, p. m1557. doi: 10.1136/bmj.m1557.

Edmond C (2020). Coronavirus fears may have driven over 300,000 UK smokers to quit, weforum.org (https://www.weforum.org/agenda/2020/05/smoking-covid19-health-coronavirus-uk-pandemic-cigarette-covid, accessed 17 July 2020).

EEA (2020). Air quality and COVID-19. Copenhagen: European Environment Agency; 2020 (https://www.eea.europa.eu/themes/air/air-quality-and-covid19, accessed 5 February 2021).

EMCDDA (2020a). COVID-19 and people who use drugs. Lisbon: European Monitoring Centre for Drugs and Drug Addiction; 2020 (https://www.emcdda.europa.eu/publications/topic-overviews/covid-19-and-people-who-use-drugs, accessed 29 June 2020).

EMCDDA (2020b). Impact of COVID-19 on drug services and help-seeking in Europe. Lisbon: European Monitoring Centre for Drugs and Drug Addiction; 2020 (https://www.emcdda.europa.eu/system/files/publications/13073/EMCDDA-Trendspotter-Covid-19_Wave-1-2.pdf, accessed 11 February 2020).

Endler M et al. (2020). How the coronavirus disease 2019 pandemic is impacting sexual and reproductive health and rights and response: Results from a global survey of providers, researchers, and policy‐makers. Acta Obstetricia et Gynecologica Scandinavica, p. aogs.14043. doi: 10.1111/aogs.14043.

European Commission (no date). European Core Health Indicators (ECHI). Brussels: European Commission (https://ec.europa.eu/health/indicators_data/indicators_en, accessed 28 March 2021).

European Commission. Joint Research Centre (2020). The likely impact of COVID-19 on education: reflections based on the existing literature and recent international datasets. LU: Publications Office (https://data.europa.eu/doi/10.2760/126686, accessed 5 February 2021).

European Health Information Gateway (no date). European Health Information Gateway: A wealth of information at your fingertips. Copenhagen: WHO Regional Office for Europe (https://gateway.euro.who.int/en/, accessed 28 March 2021).

European Medicines Agency (no date). Availability of medicines during COVID-19 pandemic (https://www.ema.europa.eu/en/human-regulatory/overview/public-health-threats/coronavirus-disease-covid-19/availability-medicines-during-covid-19-pandemic, accessed 2 February 2021).

European Monitoring Centre for Drugs and Drug Addiction (2020). Impact of COVID-19 on patterns of drug use and drug-related harms in Europe. LU: Publications Office (https://data.europa.eu/doi/10.2810/830360, accessed 4 February 2021).

European Parliament (2020). Mental health during the COVID-19 pandemic. ENVI Webinar Proceedings (https://www.europarl.europa.eu/RegData/etudes/BRIE/2020/658213/IPOL_BRI(2020)658213_EN.pdf, accessed 1 February 2021).

https://www.weforum.org/agenda/2020/05/smoking-covid19-health-coronavirus-uk-pandemic-cigarette-covid

https://www.weforum.org/agenda/2020/05/smoking-covid19-health-coronavirus-uk-pandemic-cigarette-covid

https://www.eea.europa.eu/themes/air/air-quality-and-covid19

https://www.eea.europa.eu/themes/air/air-quality-and-covid19

https://www.emcdda.europa.eu/publications/topic-overviews/covid-19-and-people-who-use-drugs

https://www.emcdda.europa.eu/publications/topic-overviews/covid-19-and-people-who-use-drugs

https://www.emcdda.europa.eu/system/files/publications/13073/EMCDDA-Trendspotter-Covid-19_Wave-1-2.pdf

https://www.emcdda.europa.eu/system/files/publications/13073/EMCDDA-Trendspotter-Covid-19_Wave-1-2.pdf

https://ec.europa.eu/health/indicators_data/indicators_en

https://data.europa.eu/doi/10.2760/126686

https://gateway.euro.who.int/en/

https://gateway.euro.who.int/en/

https://www.ema.europa.eu/en/human-regulatory/overview/public-health-threats/coronavirus-disease-covid-19/availability-medicines-during-covid-19-pandemic

https://www.ema.europa.eu/en/human-regulatory/overview/public-health-threats/coronavirus-disease-covid-19/availability-medicines-during-covid-19-pandemic



https://www.europarl.europa.eu/RegData/etudes/BRIE/2020/658213/IPOL_BRI(2020)658213_EN.pdf

https://www.europarl.europa.eu/RegData/etudes/BRIE/2020/658213/IPOL_BRI(2020)658213_EN.pdf

REFERENCES 27

Eurostat (2021a). December 2020. Euro area unemployment at 8.3%. EU at 7.5% (https://ec.europa.eu/eurostat/documents/2995521/11562919/3-01022021-AP-EN.pdf/db860f10-65e3-a1a6-e526-9d4db80904b9?t=1612091909770, accessed 5 February 2021).

Eurostat (2021b). Excess mortality – statistics (https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Excess_mortality_-_statistics&oldid=509982#:~:text=Responding%20to%20the%20increasing%20demand,occurred%20compared%20to%20the%20baseline, accessed 28 March 2021).

Eurostat (no date). Health variables of EU-SILC: Reference Metadata in Euro SDMX Metadata Structure (ESMS) (https://ec.europa.eu/eurostat/cache/metadata/en/hlth_silc_01_esms.htm, accessed 28 March 2021).

Evandrou M et al. (2020). Older and ‘staying at home’ during lockdown: informal care receipt during the COVID-19 pandemic amongst people aged 70 and over in the UK. Preprint. SocArXiv. doi: 10.31235/osf.io/962dy.

Farmer B (2020). Toxic alcohol kills more than 700 in Iran following false reports it wards off coronavirus. Telegraph.co.uk (https://www.telegraph.co.uk/global-health/science-and-disease/toxic-alcohol-kills-700-iran-following-false-reports-ward-coronavirus, accessed 17 July 2020).

Franklin N (2020). Working from home creates significant physical and mental challenges. workplaceinsight.net (https://workplaceinsight.net/working-from-home-creates-significant-physical-and-mental-challenges, accessed 12 February 2021).

Giebel C et al. (2020). A UK survey of COVID‐19 related social support closures and their effects on older people, people with dementia, and carers. International Journal of Geriatric Psychiatry, p. gps.5434. doi: 10.1002/gps.5434.

Global Health Expenditure Database (no date). Geneva: World Health Organization (https://apps.who.int/nha/database, accessed 28 March 2021).

Global Health Observatory (no date a). Indicators. The Global Health Observatory. Geneva: World Health Organization (https://www.who.int/data/gho/data/indicators, accessed 28 March 2021).

Global Health Observatory (no date b). Global Health Estimates: Life expectancy and leading causes of death and disability. The Global Health Observatory. Geneva: World Health Organization (https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates, accessed 28 March 2021).

Global Health Observatory (no date c). Prevalence of insufficient physical activity among adults aged 18+ years. The Global Health Observatory. Geneva: World Health Organization (https://www.who.int/data/gho/indicator-metadata-registry/imr-details/2381, accessed 28 March 2021).

Groarke JM et al. (2020). Loneliness in the UK during the COVID-19 pandemic: Cross-sectional results from the COVID-19 Psychological Wellbeing Study. PLOS ONE. Edited by M. Murakami, 15(9), p. e0239698. doi: 10.1371/journal.pone.0239698.

https://ec.europa.eu/eurostat/documents/2995521/11562919/3-01022021-AP-EN.pdf/db860f10-65e3-a1a6-e526-9d4db80904b9?t=1612091909770



https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Excess_mortality_-_statistics&oldid=509982#:~:text=Responding%20to%20the%20increasing%20demand,occurred%20compared%20to%20the%20baseline



https://ec.europa.eu/eurostat/cache/metadata/en/hlth_silc_01_esms.htm

https://www.telegraph.co.uk/global-health/science-and-disease/toxic-alcohol-kills-700-iran-following-false-reports-ward-coronavirus

https://www.telegraph.co.uk/global-health/science-and-disease/toxic-alcohol-kills-700-iran-following-false-reports-ward-coronavirus

https://workplaceinsight.net/working-from-home-creates-significant-physical-and-mental-challenges

https://workplaceinsight.net/working-from-home-creates-significant-physical-and-mental-challenges

https://apps.who.int/nha/database

https://apps.who.int/nha/database

https://www.who.int/data/gho/data/indicators

https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates

https://www.who.int/data/gho/indicator-metadata-registry/imr-details/2381

https://www.who.int/data/gho/indicator-metadata-registry/imr-details/2381


Huber BC et al. (2020). Alteration of physical activity during COVID-19 pandemic lockdown in young adults. Journal of Translational Medicine, 18(1), p. 410. doi: 10.1186/s12967-020-02591-7.

Hwang TJ et al. (2020). Loneliness and social isolation during the COVID-19 pandemic. International Psychogeriatrics, 32(10), pp. 1217–1220. doi: 10.1017/S1041610220000988.

IASC (2020). Interim Briefing Note Addressing Mental Health and Psychosocial Aspects of COVID-19 Outbreak (developed by the IASC’s Reference Group on Mental Health and Psychosocial Support). Geneva: Inter-Agency Standing Committee; 2020 (https://interagencystandingcommittee.org/iasc-reference-group-mental-health-and-psychosocial-support-emergency-settings/interim-briefing, accessed 27 January 2021).

ILO (2020). ILO Monitor: COVID-19 and the world of work. Fourth edition. Updated estimates and analysis. Geneva: International Labour Organization; 2020 (https://www.ilo.org/wcmsp5/groups/public/---dgreports/---dcomm/documents/briefingnote/wcms_745963.pdf, accessed 9 February 2021).

ILO (no date). Indicator description: Unemployment rate. Geneva: International Labour Organization (https://ilostat.ilo.org/resources/concepts-and-definitions/description-unemployment-rate, accessed 11 February 2021).

IOM (no date). COVID-19 and the risk of exacerbating existing vulnerabilities. Geneva: International Organization for Migration (https://www.iom.int/sites/default/files/our_work/ICP/MPR/migration_factsheet_6_covid-19_and_migrants.pdf, accessed 9 February 2021).

IPPF (2020). COVID-19 Impact: What we know so far – Ireland. London: International Planned Parenthood Federation; 10 June 2020 (https://www.ippf.org/blogs/covid-19-impact-what-we-know-so-far-ireland, accessed 27 January 2021).

Jia R et al. (2020). Young people, mental health and COVID-19 infection: the canaries we put in the coal mine. Public Health, 189, pp. 158–161. doi: 10.1016/j.puhe.2020.10.018.

Le Roux G, Sinno-Tellier S, Descatha A (2020). COVID-19: home poisoning throughout the containment period. The Lancet Public Health, 5(6), p. e314. doi: 10.1016/S2468-2667(20)30095-5.

Mahase E (2020). Covid-19: increasing demand for dialysis sparks fears of supply shortage. BMJ, p. m1588. doi: 10.1136/bmj.m1588.

Martins Van Jaarsveld G (2020). The Effects of COVID-19 Among the Elderly Population: A Case for Closing the Digital Divide. Frontiers in Psychiatry, 11, p. 577427. doi: 10.3389/fpsyt.2020.577427.

Mehrotra A et al. (2020). The Impact of the COVID-19 Pandemic on Outpatient Visits: A Rebound Emerges? doi: 10.26099/DS9E-JM36.

Miller FA et al. (2020). Vulnerability of the medical product supply chain: the wake-up call of COVID-19. BMJ Quality & Safety, p. bmjqs-2020-012133. doi: 10.1136/bmjqs-2020-012133.

https://interagencystandingcommittee.org/iasc-reference-group-mental-health-and-psychosocial-support-emergency-settings/interim-briefing



https://www.ilo.org/wcmsp5/groups/public/---dgreports/---dcomm/documents/briefingnote/wcms_745963.pdf

https://www.ilo.org/wcmsp5/groups/public/---dgreports/---dcomm/documents/briefingnote/wcms_745963.pdf

https://ilostat.ilo.org/resources/concepts-and-definitions/description-unemployment-rate

https://ilostat.ilo.org/resources/concepts-and-definitions/description-unemployment-rate

https://www.iom.int/sites/default/files/our_work/ICP/MPR/migration_factsheet_6_covid-19_and_migrants.pdf

https://www.iom.int/sites/default/files/our_work/ICP/MPR/migration_factsheet_6_covid-19_and_migrants.pdf

https://www.ippf.org/blogs/covid-19-impact-what-we-know-so-far-ireland

https://www.ippf.org/blogs/covid-19-impact-what-we-know-so-far-ireland

REFERENCES 29

Mulholland RH et al. (2020). Impact of COVID-19 on accident and emergency attendances and emergency and planned hospital admissions in Scotland: an interrupted time-series analysis. Journal of the Royal Society of Medicine, 113(11), pp. 444–453. doi: 10.1177/0141076820962447.

NOS (2020a). Physiotherapists see more physical complaints due to working from home. nos.nl, 29 August 2020 (https://nos.nl/artikel/2345833-fysiotherapeuten-zien-meer-fysieke-klachten-door-thuiswerken.html#:~:text=Fysiotherapeuten%20zien%20een%20forse%20toename,500%20fysiotherapeuten%20aan%20het%20werk, accessed 12 February 2021).

NOS (2020b). Substantial decrease in other infectious diseases due to corona measures. nos.nl (https://nos.nl/artikel/2333814-forse-daling-andere-infectieziekten-door-coronamaatregelen.html, accessed 20 July 2020).

Oakman J et al. (2020). A rapid review of mental and physical health effects of working at home: how do we optimise health?. BMC Public Health, 20(1), p. 1825. doi: 10.1186/s12889-020-09875-z.

OECD (2018). Health Care Quality and Outcomes (HCQO): 2018-19 Indicator definitions. Paris: Organisation for Economic Co-operation and Development; 2018 (http://www.oecd.org/els/health-systems/Definitions-of-Health-Care-Quality-Outcomes.pdf, accessed 28 March 2021).

OECD (2020a). Combatting COVID-19’s effect on children. Paris: Organisation for Economic Co-operation and Development; 2020 (http://www.oecd.org/coronavirus/policy-responses/combatting-covid-19-s-effect-on-children-2e1f3b2f, accessed 2 February 2021).

OECD (2020b). What is the impact of the COVID-19 pandemic on immigrants and their children? Paris: Organisation for Economic Co-operation and Development; 2020 (https://www.oecd.org/coronavirus/policy-responses/what-is-the-impact-of-the-covid-19-pandemic-on-immigrants-and-their-children-e7cbb7de, accessed 9 February 2021).

OECD and European Union (2020). Health at a Glance: Europe 2020: State of Health in the EU Cycle. OECD (Health at a Glance: Europe). doi: 10.1787/82129230-en.

Olsen SJ et al. (2020). Decreased Influenza Activity During the COVID-19 Pandemic — United States, Australia, Chile, and South Africa, 2020. Morbidity and Mortality Weekly Report, 69(37), pp. 1305–1309. doi: 10.15585/mmwr.mm6937a6.

Pan American Health Organization (2020). The use of tunnels and other technologies for disinfection of humans using chemical aspersion or UV-C Light. Washington, DC: Pan American Health Organization; 2020 (https://iris.paho.org/handle/10665.2/52066, accessed 3 September 2020).

Panteli D (2020). How are countries reorganizing non-COVID-19 health care service delivery? Cross-country analysis. COVID-19 Health System Response Monitor; 2020 (https://analysis.covid19healthsystem.org/index.php/2020/05/06/how-are-countries-reorganizing-non-covid-19-health-care-service-delivery, accessed 29 June 2020).

Patel JA et al. (2020). Poverty, inequality and COVID-19: the forgotten vulnerable. Public Health, 183, pp. 110–111. doi: 10.1016/j.puhe.2020.05.006.

https://nos.nl/artikel/2345833-fysiotherapeuten-zien-meer-fysieke-klachten-door-thuiswerken.html#:~:text=Fysiotherapeuten%20zien%20een%20forse%20toename,500%20fysiotherapeuten%20aan%20het%20werk



https://nos.nl/artikel/2333814-forse-daling-andere-infectieziekten-door-coronamaatregelen.html

https://nos.nl/artikel/2333814-forse-daling-andere-infectieziekten-door-coronamaatregelen.html

http://www.oecd.org/els/health-systems/Definitions-of-Health-Care-Quality-Outcomes.pdf

http://www.oecd.org/els/health-systems/Definitions-of-Health-Care-Quality-Outcomes.pdf

http://www.oecd.org/coronavirus/policy-responses/combatting-covid-19-s-effect-on-children-2e1f3b2f

http://www.oecd.org/coronavirus/policy-responses/combatting-covid-19-s-effect-on-children-2e1f3b2f

https://www.oecd.org/coronavirus/policy-responses/what-is-the-impact-of-the-covid-19-pandemic-on-immigrants-and-their-children-e7cbb7de



https://iris.paho.org/handle/10665.2/52066

https://analysis.covid19healthsystem.org/index.php/2020/05/06/how-are-countries-reorganizing-non-covid-19-health-care-service-delivery




Paton N (2021). PPE shortage fears returning as third wave of Covid bites. personneltoday.com (https://www.personneltoday.com/hr/ppe-shortage-fears-returning-as-third-wave-of-covid-bites/).

Power K (2020). The COVID-19 pandemic has increased the care burden of women and families. Sustainability: Science, Practice and Policy, 16(1), pp. 67–73. doi: 10.1080/15487733.2020.1776561.

RAND (no date). 36-Item Short Form Survey (SF-36). Santa Monica: RAND Corporation (https://www.rand.org/health-care/surveys_tools/mos/36-item-short-form.html, accessed 28 march 2021).

Ranney ML, Griffeth V, Jha AK (2020). Critical Supply Shortages - The Need for Ventilators and Personal Protective Equipment during the Covid-19 Pandemic. The New England Journal of Medicine, 382(18), p. e41. doi: 10.1056/NEJMp2006141.

Rausa E et al. (2020). Impact of COVID‐19 on attendances to a major emergency department: an Italian perspective. Internal Medicine Journal, 50(9), pp. 1159–1160. doi: 10.1111/imj.14972.

Rawaf S et al. (2020). Lessons on the COVID-19 pandemic, for and by primary care professionals worldwide. European Journal of General Practice, 26(1), pp. 129–133. doi: 10.1080/13814788.2020.1820479.

Regnum (2020). 37 migrants from Turkmenistan die from alcohol poisoning in Turkey, regnum.ru (https://regnum.ru/news/accidents/2892984.html, accessed 17 July 2020).

Rehm J et al. (2020). Alcohol use in times of the COVID-19: Implications for monitoring and policy. Drug and Alcohol Review, 39(4), pp. 301–304. doi: 10.1111/dar.13074.

Reliefweb (2020). The pandemic disproportionately impacts people with disabilities. New York: United Nations Office for the Coordination of Humanitarian Affairs; 2020 (https://reliefweb.int/report/world/pandemic-disproportionately-impacts-people-disabilities, accessed 8 February 2021).

RIVM (2020a). First wave of COVID-19 had major impact on regular healthcare and health. RIVM (https://www.rivm.nl/en/news/first-wave-of-covid-19-had-major-impact-on-regular-healthcare-and-health, accessed 27 January 2021).

RIVM (2020b) Volksgezondheid Toekomst Verkenning | Thema gezondheid | Leefstijl [Public Health Foresight Study | Theme health | Lifestyle]. RIVM (https://www.volksgezondheidtoekomstverkenning.nl/c-vtv/gezondheid/leefstijl#referentie-leefstijl, accessed 3 February 2021).

RIVM (2021) Policy on corona measures is tight, but compliance is still high. RIVM (https://www.rivm.nl/nieuws/beleid-coronamaatregelen-wringt-maar-naleving-vooralsnog-hoog, accessed 26 February 2021).

Rubin R (2020). COVID-19’s Crushing Effects on Medical Practices, Some of Which Might Not Survive. JAMA, 324(4), p. 321. doi: 10.1001/jama.2020.11254.

https://www.personneltoday.com/hr/ppe-shortage-fears-returning-as-third-wave-of-covid-bites/

https://www.rand.org/health-care/surveys_tools/mos/36-item-short-form.html

https://regnum.ru/news/accidents/2892984.html

https://reliefweb.int/report/world/pandemic-disproportionately-impacts-people-disabilities

https://reliefweb.int/report/world/pandemic-disproportionately-impacts-people-disabilities

https://www.rivm.nl/en/news/first-wave-of-covid-19-had-major-impact-on-regular-healthcare-and-health

https://www.rivm.nl/en/news/first-wave-of-covid-19-had-major-impact-on-regular-healthcare-and-health

https://www.volksgezondheidtoekomstverkenning.nl/c-vtv/gezondheid/leefstijl#referentie-leefstijl

https://www.volksgezondheidtoekomstverkenning.nl/c-vtv/gezondheid/leefstijl#referentie-leefstijl

https://www.rivm.nl/nieuws/beleid-coronamaatregelen-wringt-maar-naleving-vooralsnog-hoog

https://www.rivm.nl/nieuws/beleid-coronamaatregelen-wringt-maar-naleving-vooralsnog-hoog

REFERENCES 31

Sallie SN et al. (2020). Assessing international alcohol consumption patterns during isolation from the COVID-19 pandemic using an online survey: highlighting negative emotionality mechanisms. BMJ Open, 10(11), p. e044276. doi: 10.1136/bmjopen-2020-044276.

Santoli JM et al. (2020). Effects of the COVID-19 Pandemic on Routine Pediatric Vaccine Ordering and Administration — United States, 2020. Morbidity and Mortality Weekly Report, 69(19), pp. 591–593. doi: 10.15585/mmwr.mm6919e2.

Sarwari A, Goode C (2020). “I thought I could wait this out”: Fearing coronavirus, patients delayed hospital visits, putting health and lives at risk. theconversation.com (https://theconversation.com/i-thought-i-could-wait-this-out-fearing-coronavirus-patients-delayed-hospital-visits-putting-health-and-lives-at-risk-137965, accessed 1 February 2021).

Savage M (2020). Covid causes child detention crisis, and a ‘timebomb’ in adult prisons, The Guardian (https://www.theguardian.com/society/2020/may/31/covid-causes-child-detention-crisis-and-a-timebomb-in-adult-prisons?CMP=Share_iOSApp_Other, accessed 17 July 2020).

Schmidt SCE et al. (2020). Physical activity and screen time of children and adolescents before and during the COVID-19 lockdown in Germany: a natural experiment. Scientific Reports, 10(1), p. 21780. doi: 10.1038/s41598-020-78438-4.

Sim MR (2020). The COVID-19 pandemic: major risks to healthcare and other workers on the front line. Occupational and Environmental Medicine, 77(5), pp. 281–282. doi: 10.1136/oemed-2020-106567.

Simard J, Volicer L (2020). Loneliness and Isolation in Long-term Care and the COVID-19 Pandemic. Journal of the American Medical Directors Association, 21(7), pp. 966–967. doi: 10.1016/j.jamda.2020.05.006.

Stiglitz J (2020). Conquering the great divide. Washington, DC: International Monetary Fund; 2020 (https://www.imf.org/external/pubs/ft/fandd/2020/09/COVID19-and-global-inequality-joseph-stiglitz.htm, accessed 10 February 2021).

The Lancet Public Health (2020). Education: a neglected social determinant of health. The Lancet Public Health, 5(7), p. e361. doi: 10.1016/S2468-2667(20)30144-4.

The World Bank (2020). COVID-19 to Plunge Global Economy into Worst Recession since World War II (https://www.worldbank.org/en/news/press-release/2020/06/08/covid-19-to-plunge-global-economy-into-worst-recession-since-world-war-ii, accessed 5 February 2021).

Thomson S et al. (2014). Economic crisis, health systems and health in Europe: impact and implications for policy. Policy summary: 12. Copenhagen: WHO Regional Office for Europe; 2014 (https://apps.who.int/iris/handle/10665/132050?search-result=true&query=Economic+crisis%2C+health+systems+and+health+in+Europe%3A+impact+and+implications+for+policy&scope=&-rpp=10&sort_by=score&order=desc, accessed 2 February 2021).

https://theconversation.com/i-thought-i-could-wait-this-out-fearing-coronavirus-patients-delayed-hospital-visits-putting-health-and-lives-at-risk-137965



https://www.theguardian.com/society/2020/may/31/covid-causes-child-detention-crisis-and-a-timebomb-in-adult-prisons?CMP=Share_iOSApp_Other

https://www.theguardian.com/society/2020/may/31/covid-causes-child-detention-crisis-and-a-timebomb-in-adult-prisons?CMP=Share_iOSApp_Other

https://www.imf.org/external/pubs/ft/fandd/2020/09/COVID19-and-global-inequality-joseph-stiglitz.htm

https://www.imf.org/external/pubs/ft/fandd/2020/09/COVID19-and-global-inequality-joseph-stiglitz.htm

https://www.worldbank.org/en/news/press-release/2020/06/08/covid-19-to-plunge-global-economy-into-worst-recession-since-world-war-ii

https://www.worldbank.org/en/news/press-release/2020/06/08/covid-19-to-plunge-global-economy-into-worst-recession-since-world-war-ii

https://apps.who.int/iris/handle/10665/132050?search-result=true&query=Economic+crisis%2C+health+systems+and+health+in+Europe%3A+impact+and+implications+for+policy&scope=&rpp=10&sort_by=score&order=desc




Thomson S et al., editors (2015). Economic crisis, health systems and health in Europe: impact and implications for policy. Maidenhead: Open Univ. Press [u.a.] (European Observatory on Health Systems and Policies series) (https://www.euro.who.int/__data/assets/pdf_file/0008/289610/Economic-Crisis-Health-Systems-Health-Europe-Impact-implications-policy.pdf, accessed 28 March 2021).

Thomson S, Cylus J, Evetovits T (2019). Can people afford to pay for health care? New evidence on financial protection in Europe: Regional report. Copenhagen: WHO Regional Office for Europe; 2019 (https://apps.who.int/iris/bitstream/handle/10665/311654/9789289054058-eng.pdf?sequence=1&isAllowed=y, accessed 2 February 2021).

Tornaghi M et al. (2020). Physical activity levels across COVID-19 outbreak in youngsters of Northwestern Lombardy. The Journal of Sports Medicine and Physical Fitness. doi: 10.23736/S0022-4707.20.11600-1.

UN DESA (2020). The impact of COVID-19 on sport, physical activity and well-being and its effects on social development. New York: United Nations Department of Economic and Social Affairs; 2020 (https://www.un.org/development/desa/dspd/wp-content/uploads/sites/22/2020/05/PB_73.pdf, accessed 3 February 2021).

UNICEF (2020). Framework for reopening schools. New York: United Nations International Children’s Emergency Fund; 2020 (https://www.unicef.org/media/68366/file/Framework-for-reopening-schools-2020.pdf, accessed 3 September 2020).

United Nations (2020). UN Secretary-General’s policy brief: The impact of COVID-19 on women. New York: United Nations; 2020 (https://www.unwomen.org/en/digital-library/publications/2020/04/policy-brief-the-impact-of-covid-19-on-women, accessed 22 July 2020).

United Nations (no date a). SDG Indicators: Metadata repository. Sustainable Development Goals. New York: United Nations (https://unstats.un.org/sdgs/metadata/, accessed 28 March 2021).

United Nations (no date b). Indicator 8.5.2: Unemployment rate, by sex, age and persons with disabilities. SDG Indicators: Metadata repository. Sustainable Development Goals. New York: United Nations (https://unstats.un.org/sdgs/metadata/files/Metadata-08-05-02.pdf, accessed 28 March 2021).

United Nations Europe and Central Asia Issue-Based Coalition (no date). Gender equality and the COVID-19 outbreak: Key messages and advocacy points from the Europe and Central Asia Regional Issue-Based Coalition on Gender (https://eca.unwomen.org/en/digital-library/publications/2020/04/gender-equality-and-covid19-outbreak-key-messages-from-regional-issue-based-coalition-on-gender, accessed 22 July 2020).

USGLC (2020). COVID-19 Brief: Impact on Refugees. Washington, DC: U.S. Global Leadership Coalistion; 2020 (https://www.usglc.org/coronavirus/refugees, accessed 9 February 2021).

Vazquez-Vazquez A et al. (2021). The impact of the Covid-19 lockdown on the experiences and feeding practices of new mothers in the UK: Preliminary data from the COVID-19 New Mum Study. Appetite, 156, p. 104985. doi: 10.1016/j.appet.2020.104985.

https://www.euro.who.int/__data/assets/pdf_file/0008/289610/Economic-Crisis-Health-Systems-Health-Europe-Impact-implications-policy.pdf



https://apps.who.int/iris/bitstream/handle/10665/311654/9789289054058-eng.pdf?sequence=1&isAllowed=y

https://apps.who.int/iris/bitstream/handle/10665/311654/9789289054058-eng.pdf?sequence=1&isAllowed=y

https://www.un.org/development/desa/dspd/wp-content/uploads/sites/22/2020/05/PB_73.pdf

https://www.un.org/development/desa/dspd/wp-content/uploads/sites/22/2020/05/PB_73.pdf

https://www.unicef.org/media/68366/file/Framework-for-reopening-schools-2020.pdf

https://www.unicef.org/media/68366/file/Framework-for-reopening-schools-2020.pdf

https://www.unwomen.org/en/digital-library/publications/2020/04/policy-brief-the-impact-of-covid-19-on-women

https://www.unwomen.org/en/digital-library/publications/2020/04/policy-brief-the-impact-of-covid-19-on-women

https://unstats.un.org/sdgs/metadata/

https://unstats.un.org/sdgs/metadata/files/Metadata-08-05-02.pdf

https://eca.unwomen.org/en/digital-library/publications/2020/04/gender-equality-and-covid19-outbreak-key-messages-from-regional-issue-based-coalition-on-gender



https://www.usglc.org/coronavirus/refugees

REFERENCES 33

Verbeek H et al. (2020). Allowing Visitors Back in the Nursing Home During the COVID-19 Crisis: A Dutch National Study Into First Experiences and Impact on Well-Being. Journal of the American Medical Directors Association, 21(7), pp. 900–904. doi: 10.1016/j.jamda.2020.06.020.

Verschuuren M, van Oers H, editors (2019). Introduction [in] Population Health Monitoring. Cham: Springer International Publishing, pp. 1–9. doi: 10.1007/978-3-319-76562-4_2.

Wageningen University & Research (2020). Higher-educated and obese people eat less healthy during lockdown (https://www.wur.nl/en/show/Higher-educated-and-obese-people-eat-less-healthy-during-lockdown.htm, accessed 4 November 2020).

Webb A, McQuaid R, Rand S (2020). Employment in the informal economy: implications of the COVID-19 pandemic. International Journal of Sociology and Social Policy, 40(9/10), pp. 1005–1019. doi: 10.1108/IJSSP-08-2020-0371.

Wenham C (2020). The gendered impact of the COVID-19 crisis and post-crisis period. Study requested by the FEMM committee. Strasbourg: European Parliament; 2020 (https://www.europarl.europa.eu/RegData/etudes/STUD/2020/658227/IPOL_STU(2020)658227_EN.pdf, accessed 1 February 2021).

WHO Epi Data (no date). Measles and rubella surveillance. Copenhagen: WHO Regional Office for Europe (https://www.euro.who.int/en/health-topics/disease-prevention/vaccines-and-immunization/publications/surveillance-and-data/who-epidata, accessed 28 March 2021).

World Health Organization (2018). 2018 Global Reference List of 100 Core Health Indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/bitstream/handle/10665/259951/WHO-HIS-IER-GPM-2018.1-eng.pdf;jsessionid=A8F7CEBD0F8190B81730DCC21DB4ED44?sequence=1, accessed 28 March 2021).

World Health Organization (2020a). Addressing violence against children, women, and older people during the COVID-19 pandemic: key actions. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/WHO-2019-nCoV-Violence_actions-2020.1, accessed 2 February 2021).

World Health Organization (2020b). Alcohol and COVID-19: what you need to know. Copenhagen: WHO Regional Office for Europe; 2020 (https://www.euro.who.int/__data/assets/pdf_file/0010/437608/Alcohol-and-COVID-19-what-you-need-to-know.pdf, accessed 17 July 2020).

World Health Organization (2020c). Children and adolescents deprived of liberty in the context of the COVID-19 response in the WHO European Region. Copenhagen: WHO Regional Office for Europe; 2020 (https://www.euro.who.int/__data/assets/pdf_file/0011/458228/youth-detention-COVID-19-factsheet.pdf, accessed 8 February 2021).

World Health Organization (2020d). Gender and COVID-19: advocacy brief, 14 May 2020. Technical documents. Geneva: World Health Organization; 2020 (https://apps.who.int/iris/handle/10665/332080, accessed 1 February 2021).

https://www.wur.nl/en/show/Higher-educated-and-obese-people-eat-less-healthy-during-lockdown.htm

https://www.wur.nl/en/show/Higher-educated-and-obese-people-eat-less-healthy-during-lockdown.htm

https://www.europarl.europa.eu/RegData/etudes/STUD/2020/658227/IPOL_STU(2020)658227_EN.pdf

https://www.europarl.europa.eu/RegData/etudes/STUD/2020/658227/IPOL_STU(2020)658227_EN.pdf

https://www.euro.who.int/en/health-topics/disease-prevention/vaccines-and-immunization/publications/surveillance-and-data/who-epidata

https://www.euro.who.int/en/health-topics/disease-prevention/vaccines-and-immunization/publications/surveillance-and-data/who-epidata

https://apps.who.int/iris/bitstream/handle/10665/259951/WHO-HIS-IER-GPM-2018.1-eng.pdf;jsessionid=A8F7CEBD0F8190B81730DCC21DB4ED44?sequence=1



https://www.who.int/publications/i/item/WHO-2019-nCoV-Violence_actions-2020.1

https://www.euro.who.int/__data/assets/pdf_file/0010/437608/Alcohol-and-COVID-19-what-you-need-to-know.pdf

https://www.euro.who.int/__data/assets/pdf_file/0010/437608/Alcohol-and-COVID-19-what-you-need-to-know.pdf

https://www.euro.who.int/__data/assets/pdf_file/0011/458228/youth-detention-COVID-19-factsheet.pdf

https://www.euro.who.int/__data/assets/pdf_file/0011/458228/youth-detention-COVID-19-factsheet.pdf

https://apps.who.int/iris/handle/10665/332080



World Health Organization (2020e). Influenza update - 371. Geneva: World Health Organization; 2020 (https://www.who.int/influenza/surveillance_monitoring/updates/2020_07_06_surveillance_update_371.pdf?ua=1, accessed 9 July 2020).

World Health Organization (2020f). Preparedness, prevention and control of COVID-19 in prisons and other places of detention: Interim guidance 15 March 2020. Technical documents. Copenhagen: WHO Regional Office for Europe; 2020 (https://apps.who.int/iris/handle/10665/336525?search-result=true&query=Preparedness%2C+prevention+and+control+of+COVID-19+in+prisons+and+other+places+of+detention&scope=&rpp=10&sort_by=score&order=desc, accessed 8 February 2021).

World Health Organization (2020g). Preventing the COVID-19 pandemic from causing an antibiotic resistance catastrophe. Copenhagen: WHO Regional Office for Europe; 2020 (https://www.euro.who.int/en/health-topics/disease-prevention/antimicrobial-resistance/news/news/2020/11/preventing-the-covid-19-pandemic-from-causing-an-antibiotic-resistance-catastrophe#:~:text=According%20to%20research%20conducted%20by,of%20the%20-COVID%2D19%20pandemic, accessed 27 January 2021).

World Health Organization (2020h). Promoting the health of migrant workers in the WHO European Region during COVID-19. Interim guidance, 6 November 2020. Technical documents. Copenhagen: WHO Regional Office for Europe; 2020 (https://apps.who.int/iris/handle/10665/336549?search-result=true&query=Promoting+the+health+of+Migrant+Workers+in+the+WHO+European+Region+during+COVID-19&scope=&rpp=10&sort_by=score&order=desc, accessed 10 February 2021).

World Health Organization (2020i). Pulse survey on continuity of essential health services during the COVID-19 pandemic: Interim report. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/WHO-2019-nCoV-EHS_continuity-survey-2020.1, accessed 1 February 2021).

World Health Organization (2020j). Rapid assessment of service delivery for NCDs during the COVID-19 pandemic. Geneva: World Health Organization; 2020 (https://www.who.int/publications/m/item/rapid-assessment-of-service-delivery-for-ncds-during-the-covid-19-pandemic, accessed 29 June 2020).

World Health Organization (2020k). Shortage of personal protective equipment endangering health workers worldwide. Geneva: World Health Organization; 2020 (https://www.who.int/news/item/03-03-2020-shortage-of-personal-protective-equipment-endangering-health-workers-worldwide, accessed 2 February 2021).

World Health Organization (2020l). Strengthening the health system response to COVID-19: technical guidance #1: maintaining the delivery of essential health care services while mobilizing the health workforce for the COVID-19 response. 18 April 2020. Technical documents. Copenhagen: WHO Regional Office for Europe, 2020 (https://apps.who.int/iris/handle/10665/332559, accessed 1 February 2021).

https://www.who.int/influenza/surveillance_monitoring/updates/2020_07_06_surveillance_update_371.pdf?ua=1

https://www.who.int/influenza/surveillance_monitoring/updates/2020_07_06_surveillance_update_371.pdf?ua=1

https://apps.who.int/iris/handle/10665/336525?search-result=true&query=Preparedness%2C+prevention+and+control+of+COVID-19+in+prisons+and+other+places+of+detention&scope=&rpp=10&sort_by=score&order=desc




https://www.euro.who.int/en/health-topics/disease-prevention/antimicrobial-resistance/news/news/2020/11/preventing-the-covid-19-pandemic-from-causing-an-antibiotic-resistance-catastrophe#:~:text=According%20to%20research%20conducted%20by,of%20the%20COVID%2D19%20pandemic





https://apps.who.int/iris/handle/10665/336549?search-result=true&query=Promoting+the+health+of+Migrant+Workers+in+the+WHO+European+Region+during+COVID-19&scope=&rpp=10&sort_by=score&order=desc



https://www.who.int/publications/i/item/WHO-2019-nCoV-EHS_continuity-survey-2020.1

https://www.who.int/publications/m/item/rapid-assessment-of-service-delivery-for-ncds-during-the-covid-19-pandemic



https://www.who.int/news/item/03-03-2020-shortage-of-personal-protective-equipment-endangering-health-workers-worldwide





REFERENCES 35

World Health Organization (2020m). WHO Regional Office for Europe Microbial Medicines Consumption (AMC) Network: AMC data 2011–2017). Copenhagen: WHO Regional Office for Europe; 2020 (https://www.euro.who.int/en/publications/abstracts/who-regional-office-for-europe-antimicrobial-medicines-consumption-amc-network.-amc-data-20112017-2020, accessed 28 March 2021).

World Health Organization (2021). Social determinants of health. Geneva: World Health Organization; 2020 (https://www.who.int/gender-equity-rights/understanding/sdh-definition/en/#:~:text=Social%20determinants%20of%20health%E2%80%93The,global%2C%20national%20and%20local%20levels, accessed 5 February 2021).

World Health Organization (no date a). EPHO1: Surveillance of population health and wellbeing, The 10 Essential Public Health Operations. Copenhagen: WHO Regional Office for Europe (https://www.euro.who.int/en/health-topics/Health-systems/public-health-services/policy/the-10-essential-public-health-operations/epho1-surveillance-of-population-health-and-wellbeing, accessed 22 June 2020).

World Health Organization (no date b). Immunization Analysis and Insights: Surveillance for Vaccine Preventable Diseases (VPDs). Geneva: World Health Organization (https://www.who.int/teams/immunization-vaccines-and-biologicals/immunization-analysis-and-insights/surveillance/surveillance-for-vpds, accessed 28 March 2021).

World Health Organization (no date c). Weekly Epidemiological Record. Geneva: World Health Organization (https://www.who.int/publications/journals/weekly-epidemiological-record, accessed 28 March 2021).

World Health Organization (no date d). Universal Health Coverage. Geneva: World Health Organization (https://www.who.int/health-topics/universal-health-coverage#tab=tab_1, accessed 16 March 2021).

World Health Organization (no date e). Mental health and COVID-19. Copenhagen: WHO Regional Office for Europe (https://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/technical-guidance/mental-health-and-covid-19, accessed 29 June 2020).

World Health Organization (no date f). Coronavirus disease (COVID-19) advice for the public: Mythbusters. Geneva: World Health Organization (https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/myth-busters, accessed 29 June 2020).

World Health Organization (no date g). Record number of countries contribute data revealing disturbing rates of antimicrobial resistance. Geneva: World Health Organization (https://www.who.int/news-room/detail/01-06-2020-record-number-of-countries-contribute-data-revealing-disturbing-rates-of-antimicrobial-resistance, accessed 9 July 2020).

World Health Organization (no date h). WHO and UNICEF warn of a decline in vaccinations during COVID-19. Geneva: World Health Organization (https://www.who.int/news-room/detail/15-07-2020-who-and-unicef-warn-of-a-decline-in-vaccinations-during-covid-19, accessed 20 July 2020).

https://www.euro.who.int/en/publications/abstracts/who-regional-office-for-europe-antimicrobial-medicines-consumption-amc-network.-amc-data-20112017-2020

https://www.euro.who.int/en/publications/abstracts/who-regional-office-for-europe-antimicrobial-medicines-consumption-amc-network.-amc-data-20112017-2020

https://www.who.int/gender-equity-rights/understanding/sdh-definition/en/#:~:text=Social%20determinants%20of%20health%E2%80%93The,global%2C%20national%20and%20local%20levels



https://www.euro.who.int/en/health-topics/Health-systems/public-health-services/policy/the-10-essential-public-health-operations/epho1-surveillance-of-population-health-and-wellbeing

https://www.euro.who.int/en/health-topics/Health-systems/public-health-services/policy/the-10-essential-public-health-operations/epho1-surveillance-of-population-health-and-wellbeing

https://www.who.int/teams/immunization-vaccines-and-biologicals/immunization-analysis-and-insights/surveillance/surveillance-for-vpds



https://www.who.int/publications/journals/weekly-epidemiological-record

https://www.who.int/health-topics/universal-health-coverage#tab=tab_1

https://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/technical-guidance/mental-health-and-covid-19

https://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/technical-guidance/mental-health-and-covid-19

https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/myth-busters

https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/myth-busters

https://www.who.int/news-room/detail/01-06-2020-record-number-of-countries-contribute-data-revealing-disturbing-rates-of-antimicrobial-resistance



https://www.who.int/news-room/detail/15-07-2020-who-and-unicef-warn-of-a-decline-in-vaccinations-during-covid-19

https://www.who.int/news-room/detail/15-07-2020-who-and-unicef-warn-of-a-decline-in-vaccinations-during-covid-19


World Health Organization and Human Reproduction Programme (2020). COVID-19 and violence against women. What the health sector/system can do. Geneva: World Health Organization (https://www.who.int/reproductivehealth/publications/vaw-covid-19/en, accessed 22 July 2020).

Yach D (2020). Tobacco Use Patterns in Five Countries During the COVID-19 Lockdown. Nicotine & Tobacco Research, p. ntaa097. doi: 10.1093/ntr/ntaa097.

https://www.who.int/reproductivehealth/publications/vaw-covid-19/en

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World Health Organization Regional Office for EuropeUN City, Marmorvej 51 DK-2100, Copenhagen Ø, DenmarkTel: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: [email protected] Website: www.euro.who.int

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The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves.

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