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Background To achieve elimination of hepatitis C virus (HCV) infection, limited resources can be best allocated through estimation of “care cascades” among groups disproportionately affected. In San Francisco and elsewhere, these groups include young (age ≤ 30 years) people who inject drugs (YPWID), men who have sex with men who inject drugs (MSM-IDU), and low-income trans women. Methods We developed cross-sectional HCV care cascades for YPWID, MSM-IDU, and trans women using diverse data sources. Population sizes were estimated using an inverse variance-weighted average of estimates from the peer-reviewed literature between 2013 and 2019. Proportions of past/current HCV infection, diagnosed infection, treatment initiation, and evidence of cure (sustained virologic response at 12 weeks posttreatment) were estimated from the literature using data from 7 programs and studies in San Francisco between 2015 and 2020. Results The estimated number of YPWID in San Francisco was 3748; 58.4% had past/current HCV infection, of whom 66.4% were diagnosed with current infection, 9.1% had initiated treatment, and 50% had confirmed cure. The corresponding figures for the 8135 estimated MSM-IDU were: 29.4% with past/current HCV infection, 70.3% diagnosed with current infection, 28.4% initiated treatment, and 38.9% with confirmed cure. For the estimated 951 low-income trans women, 24.8% had past/current HCV infection, 68.9% were diagnosed with current infection, 56.5% initiated treatment, and 75.5% had confirmed cure. Conclusions In all 3 populations, diagnosis rates were relatively high; however, attention is needed to urgently increase treatment initiation in all groups, with a particular unmet need among YPWID.

Background Nature experiences have been shown to promote physical, emotional, mental and overall health. However, low-income youth often face inequities in access to nature. The purpose of this study was to evaluate the impact of a 15-week nature-based education (NBE) intervention on health-related quality of life (HRQoL) of low-income youth. Methods A total of 362 low-income youth (ages 9–15) in St. Louis, MO, USA, participated in this study. Study participants completed a pre- and post-intervention survey that included validated measures of six HRQoL domains (Physical Activity, Emotional Health Functioning, School Functioning, Social Functioning, Family Functioning and overall HRQoL). Random effects analysis of covariance was used to test for significant differences in HRQoL scores between the intervention and control groups, after adjusting for school, age, previous nature exposure, and Science, Technology, Engineering and Mathematics capacity. Results After the intervention period, youth in the NBE intervention group experienced improvements in all HRQoL domain scores (P Conclusions NBE may have a positive impact on the HRQoL of low-income youth. Further investigations examining the influence of nature-based activities on youth health outcomes are warranted.

In the present study, we examined the associations between physical characteristics of neighborhoods and sleep health outcomes and assessed the mediating role of physical activity in these associations. A longitudinal study (the Pittsburgh Hill/Homewood Research on Eating, Shopping, and Health (PHRESH) Zzz Study; n = 1,051) was conducted in 2 low-income, predominately African-American neighborhoods in Pittsburgh, Pennsylvania, with repeated measures of neighborhood characteristics and sleep health outcomes from 2013 to 2018. Built environment measures of walkability, urban design, and neighborhood disorder were captured from systematic field observations. Sleep health outcomes included insufficient sleep, sleep duration, wakefulness after sleep onset, and sleep efficiency measured from 7-day actigraphy data. G-computations based on structural nested mean models were used to examine the total effects of each built environment feature, and causal mediation analyses were used to evaluate direct and indirect effects operating through physical activity. Urban design features were associated with decreased wakefulness after sleep onset (risk difference (RD) = −1.26, 95% confidence interval (CI): −4.31, −0.33). Neighborhood disorder (RD = −0.46, 95% CI: −0.86, −0.07) and crime rate (RD = −0.54, 95% CI: −0.93, −0.08) were negatively associated with sleep efficiency. Neighborhood walkability was not associated with sleep outcomes. We did not find a strong and consistent mediating role of physical activity. Interventions to improve sleep should target modifiable factors, including urban design and neighborhood disorder.

This study tested the preliminary effectiveness of an electronic health record (EHR)-automated population health management (PHM) intervention for smoking cessation among adult patients of a federally qualified health center in Chicago. Participants (N = 190; 64.7% women, 82.1% African American/Black, 8.4% Hispanic/Latino) were self-identified as smokers, as documented in the EHR, who completed the baseline survey of a longitudinal “needs assessment of health behaviors to strengthen health programs and services.” Four weeks later, participants were randomly assigned to the PHM intervention (N = 97) or enhanced usual care (EUC; N = 93). PHM participants were mailed a single-page self-determination theory (SDT)-informed letter that encouraged smoking cessation or reduction as an initial step. The letter also addressed low health literacy and low income. PHM participants also received automated text messages on days 1, 5, 8, 11, and 20 after the mailed letter. Two weeks after mailing, participants were called by the Illinois Tobacco Quitline. EUC participants were e-referred following a usual practice. Participants reached by the quitline were offered behavioral counseling and nicotine replacement therapy. Outcome assessments were conducted at weeks 6, 14, and 28 after the mailed letter. Primary outcomes were treatment engagement, utilization, and self-reported smoking cessation. In the PHM arm, 25.8% of participants engaged in treatment, 21.6% used treatment, and 16.3% were abstinent at 28 weeks. This contrasts with no quitline engagement among EUC participants, and a 6.4% abstinence rate. A PHM approach that can reach all patients who smoke and address unique barriers for low-income individuals may be a critical supplement to clinic-based care.

Cooking is a complex behavior associated with more frequent and nutrient-dense family meals. The Cook Together, Eat Together (CTET) social marketing program used formative, process, and outcome evaluations over a 3-year period to design a program to increase fruit and vegetable intake and frequency of family meals. We used a quasi-experimental, mixed-methods design with a nonequivalent comparison group to evaluate fruit and vegetable intake and family meals. Eight focus groups of mothers in low-income families with young children revealed two predominant behavioral mediators: (i) importance of family time and (ii) desire for children to learn to cook and become self-sufficient adults. Program design was grounded in formative evaluation and organized by the four Ps of social marketing: (i) product—learning to prepare healthy meals while teaching children to cook; (ii) price—lowered by reducing barriers of food cost, kitchen clean-up, meal planning, grocery shopping; (iii) placement—in neighborhood gathering places with a “cooking social”; and (iv) promotion—flyers, newsletters, and social media. Outcome indicators were assessed pre/post intervention with questions from instruments validated for the audience. Significant changes (n = 68, p ≥ .002, Bonferroni adjustment for p = .05, Cohen’s d = .50 medium effect size) were found in consumption of fruits and vegetables with an average increase of half cup each per day. CTET participation significantly increased fruits and vegetables served and eaten at family meals. A social marketing approach can help families with young children increase fruit and vegetable consumption.

Background With one in eight preschoolers classified as obese in the USA, childhood obesity remains a significant public health issue. This study examined rural–urban differences in low-income preschoolers’ body mass index z-scores (BMIz), eating behaviors, dietary quality, physical activity (PA) and screen time. Methods Pre-intervention data from 572 preschooler-parent dyads participating in a randomized, controlled obesity prevention trial in the Midwest USA were analyzed. We examined the associations among living in rural versus urban areas, child BMIz and child obesity-related behaviors, including eating behaviors, dietary quality, PA and screen time. Results Rural children had higher BMIz, more emotional overeating behaviors and more time spent playing outdoors compared with urban children. We found no associations between children living in rural versus urban areas and dietary quality and screen time. Conclusions The study found that rural–urban differences in BMIz may start as early as 3–4 years of age, if not earlier. To reverse the weight-related health disparities between rural and urban low-income preschoolers, structural changes in rural locations and family supports around coping skills may be needed.

Background In urbanized, low-income cities with high rates of congestion, delivery of antiepileptic drugs (AEDs) by unmanned aerial vehicles (drones) to people with epilepsy for both emergency and non-urgent distribution may prove beneficial. Methods Conakry is the capital of the Republic of Guinea, a low-income sub-Saharan African country (2018 per capita gross national income US$830). We computed the number of drones and delivery times to distribute AEDs from a main urban hospital to 27 pre-identified gas stations, mosques and pharmacies and compared these to the delivery times of a personal vehicle. Results We predict that a single drone could serve all pre-identified delivery locations in Conakry within a 20.4-h period. In an emergency case of status epilepticus, 8, 20 and 24 of the 27 pre-identified destinations can be reached from the hub within 5, 10 and 15 min, respectively. Compared with the use of a personal vehicle, the response time for a drone is reduced by an average of 78.8% across all times of the day. Conclusions Drones can dramatically reduce the response time for both emergency and routine delivery of lifesaving medicines. We discuss the advantages and disadvantages of such a drone delivery model with relevance to epilepsy. However, the commissioning of a trial of drones for drug delivery in related diseases and geographies is justified.

Echoing the call to incorporate the intersectionality framework into studies of gender structure, this paper applied the framework to re-analyse the quantitative and qualitative findings of an evaluation study on a women empowerment community project in Hong Kong. This effort revealed the importance of the gender structure’s dimension of sexual division of labour and the intersectional effects of gender, race and class in explaining the mixed traditional and progressive views in different items within a domain and across different domains of the gender division of labour, specifically the marital, parental, employment, social activities and education domains. The low-income migrant women have upheld different traditional ideas in these domains. However, in contrast with the richer and local women who also shared these traditional views, low-income migrant women in this study questioned some prevailing ideas in these domains, due to their need to survive the conditions defined by the intersection of gender, race and class. The findings of this study, despite being preliminary and limited, demonstrate the significance and feasibility of studying gender structure adopting the perspective of intersectionality. Arguably, this lack of understanding of the intersectional effects diminishes the effectiveness of community intervention. In light of the paucity of research adopting the intersectionality framework in the community development field in general, and a similar deficit in the feminist and community development fields in Hong Kong in particular, the failure to adopt the intersectionality framework by the community project under consideration is understandable. It is likely that as this framework becomes more prominent in the future, given its potential to offer deeper insight into the dynamics of gender structure, community interventions for women of different identities could be strengthened.

Driven by the COVID-19 pandemic, many in-person health behavior interventions were compelled to quickly pivot to a virtual format with little time or capacity to reflect on or examine possible equity-related implications of a format that required digital access and remote learning skills. Using a parenting program for low-income families as a case study, this paper (a) outlines the process of adapting the program from an in-person to a virtual format and (b) examines the equity-related implications of this adaptation. Parents Connect for Healthy Living (PConnect) is a 10-session empowerment-focused parenting intervention designed to promote family health for Head Start families. In 2020, PConnect was adapted over a 6-month period from an in-person to a virtual format due to the advent of the COVID-19 pandemic. Three core elements were retained in the adaptation; session content, provision of coaching support for facilitators, and the co-facilitation model. Key modifications include session length, group composition, and language of program delivery. Head Start and PConnect records provided data to compare reach, acceptability, and appropriateness of virtual and in-person PConnect. Seventy-eight parents enrolled in the in-person program and 58 in the virtual program. Participant demographics and satisfaction were similar across formats, and demographics similar to the general Head Start population. Participation was higher in the virtual format. Parents participated in the virtual program primarily via smart phones (68%). This case study supports the acceptability and appropriateness of virtual parenting programs in ethnically diverse, low-resource settings.The purpose of this study was to examine the process of adapting an in-person health and empowerment parenting program, Parents Connect for Healthy Living (PConnect), to a virtual format, and examine if this adaptation and implementation of the virtual format led to inequities. Modifications to in-person PConnect to accommodate a virtual format included session length, group composition, and language of program delivery. Participant demographics and satisfaction were similar across the in-person and virtual formats. Attendance was slightly higher in the virtual format, and differences in attendance rates by race/ethnicity in the virtual program were less apparent. Findings from this case study indicate future programs for parents in low-resource settings should consider a virtual or hybrid approach.

This article argues that educational institutions can transmit cultural capital in the form of help-seeking dispositions (feeling empowered to ask for and receive help) and specialized knowledge (information about how to gain access to resources) that can positively impact students’ academic outcomes. Additionally, this article questions the perception that educational institutions function primarily as agents of social reproduction, by showing that institutional agents such as high school teachers and administrators can function as “cultural guides” to bolster students’ opportunities for social mobility. Drawing on interviews with graduates of King and Chavez, two early college high schools which target low-income, first-generation college students, I find that King graduates were more strategic help-seekers and were more likely to use campus-based resources than their counterparts at Chavez, in part because their school’s curriculum explicitly and systematically taught this skill. This article challenges the perception that teachers and administrators function exclusively as gatekeepers in educational institutions. Instead, the data presented show that these institutional agents can also function as “cultural guides” who transmit cultural capital in the form of help-seeking values and behaviors to students from economically marginalized communities; promoting their upward mobility.

Sociologists have shown how searches for rental housing reproduce inequalities by race/ethnicity and household income in the United States. Yet scholars know comparatively less about how legal status may also limit access to shelter. To address this gap, this article compares the housing careers of 30 low-income, undocumented/mixed-status, Mexican, Central American, and South American families with those of ten low-income, predominantly Mexican, U.S. citizen/LPR families across 103 total moves in Los Angeles, California. Though citizen and undocumented renters moved for similar reasons, the process of finding a new home varied substantially across these two groups. Renters’ legal status became salient during the screening portion of rental applications, which requested a credit and background check, a verifiable income, and banking information for each household adult. As a result, undocumented renters were excluded from most formal rentals. Instead, these families searched for sympathetic managers or doubled up with friends, family members, and non-kin. Despite these barriers, undocumented and mixed-status families achieved greater housing security over time by transitioning from guests to hosts in doubled up homes. These findings extend prior research on how housing searches stratify movers, the housing careers of Latino immigrant families, and the punitive consequences of illegality.

Background community ageing in place, advancing better living for elders (CAPABLE), which is a biobehavioural environmental approach by addressing individual capacities and the home environment, aims to reduce the impact of disability among low-income older adults. Objective this meta-analysis aims to elucidate the efficacy of the CAPABLE program on related outcomes in low-income older adults. Methods a systematic search of MEDLINE/PubMed, CINAHL and EMBASE was conducted for articles published up to August 2022. A systematic review and meta-analysis were performed to calculate the pooled effect sizes of the efficacy of the CAPABLE program on home safety hazards, activities of daily living (ADLs), instrumental ADLs (IADLs), depression, falls efficacy, pain and quality of life. Results seven studies involving 2,921 low-income older adults (1,117 as the CAPABLE group and 1,804 served as a control) with an average age ranging from 65 to 79 were included in the present meta-analysis. Pre–post effect analyses showed that CAPABLE was significantly associated with lower home safety hazards, ADLs, IADLs, depression, falls efficacy, pain and quality of life. Additionally, there were statistically significant associations between the CAPABLE program with improvements in ADLs, IADLs and quality of life compared with controls. Conclusion CAPABLE intervention may be a promising strategy to reduce health disparities, and disability limitations, and improve the quality of life in low-income community-dwelling older adults who suffer from disabilities by addressing both the person and the environment.

Housing microfinance schemes for self-organized housing have been incorporated into Mexican housing policies since 2007. This is the result of World Bank loans to Mexico but also of housing activists who for decades have advocated for the development of financial instruments to support the ‘social production of housing’—a concept defined by them as a type of housing production geared to meet families’ shelter needs rather than to enhance capital accumulation. While these World Bank housing loans were mainly oriented to strengthen the housing finance sector, the housing activists pushed for the inclusion of saving and credit cooperatives as housing microfinance providers. These cooperatives seek to promote at the local level, alternative development projects built on solidarity economy principles. Taking inspiration from critical literature on the co-optation of progressive actors by international financial institutions we highlight the activists’ agency and examine their role at the community level. We argue that processes of co-optation pushed by international financial institutions can always be contested and negotiated at a local level. We propose that, in this case, the engagement of progressive actors such as saving and credit cooperatives working according to principles of the solidarity economy could open political opportunities to subvert financial rationalities inscribed in the housing finance schemes of the World Bank.

Background One of the main problems facing cardiovascular rehabilitation (CR) is patient care and adherence. However, due to the low level of economic income of the patients who are cared for in our center, the possibility of going to CR in a conventional way is very difficult since they do not have the necessary resources to cover transportation, cost of the sessions, among others. It has been shown that the greater the number of sessions attended by the patient, the greater the reduction in cardiovascular risk, however the role of a hybrid program with a decreased number of face-to-face sessions has not been established. Purpose Present the results of a hybrid training program (in-hospital plus home) in a low-income population. Education through supervised sessions plus home physical training in a patient with bases for exercise can improve their adherence with better results. Methods A cohort of patients with heart disease who were referred to the Cardiovascular Rehabilitation program between May 2017 and February 2019 was included. The socioeconomic level was classified into 6 strata according to occupation, income, housing, economic dependents, place of origin and family health status. After risk stratification, the patients participated in a hybrid program that consisted of 6 in-hospital sessions, once a week, in which the training to be carried out at home was prescribed by means of a triptych. An exercise test was performed before and after completing the program, as well as psychological and nutritional intervention. Statistical analysis was performed using SPSS 21.0 software. All p values less than 0.05 were considered significant. Results In the study period, of the total number of patients discharged for heart disease from the hospital, 61% were referred to cardiovascular rehabilitation, of which only 45% (n=39) completed the program, the reasons for dropping out were multiple and the lowest socioeconomic level (1) was the most frequent (figure 1). The main referral diagnosis was ischemic heart disease in 82%. The majority of patients were men, 95%. A significant improvement was observed in load METs, maximum heart rate, heart rate recovery (figure 2). Conclusion The implementation of a hybrid cardiovascular rehabilitation program (in-hospital + home) was associated with an improvement in the exercise test parameters of patients who successfully completed the program. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

A burgeoning body of scholarship addresses how low-income first generation (LIFG) college students, across racial groups, navigate communication with their families about their experiences of class-based dissonance at socioeconomically elite institutions. Yet, there is scant corollary research addressing how LIFG students of color navigate communication with their families regarding experiences of racial dissonance and racism on campuses that are both socioeconomically elite and predominantly white. This study examines disjunctures in familial perceptions and interpretations regarding race and racism consequent to intergenerational educational mobility for LIFG students of color, whose parents are unlikely to have had analogous experiences of complete occupational and residential immersion in socioeconomically elite and predominantly white institutional environments. This work highlights an important gap in the academic literature on first-generation students at the intersections of race, class, parental educational attainment level, and immigration dynamics. Without a race-conscious analytic lens, class-based understandings of LIFG college students and their families remain incomplete.

We use the U.S. Department of Housing and Urban Development’s Housing Choice Voucher program as a setting to evaluate the interaction of homeownership and race on the wealth accumulation of low-income households. Using a within-treatment difference-in-differences framework, we establish that low-income households that receive assistance in owning a home experience increased wealth accumulation relative to their tenure as renters. These wealth gains are not present among low-income minority households. Our findings provide evidence that homeownership is a driver of wealth formation for low-income households and that homeownership does not inherently reduce racial disparities in wealth. (JEL G51, J15, R21).

We quantitatively investigate the welfare costs of increasing tax revenues in low-income countries. We consider three tax instruments: consumption, labour income and capital income taxes. The analysis is based on a general equilibrium model featuring heterogeneous agents, incomplete financial markets, and rural and urban areas. We calibrate the model to Ethiopia and decompose the welfare costs into their aggregate and distributional components. We find that changing taxes alter the composition of demand. This, together with limited labour mobility, causes the incidence of higher taxes to fall disproportionately on the rural population, regardless of the instrument. Consumption taxes are the instrument with the largest welfare loss.

Introduction In July 2018, the U.S. Department of Housing and Urban Development passed a rule requiring public housing authorities to implement smoke-free housing (SFH) policies. We measured secondhand smoke (SHS) exposure immediately before, and repeatedly up to 36 months post-SFH policy implementation in a purposeful sample of 21 New York City (NYC) high-rise buildings (>15 floors): 10 NYC Housing Authority (NYCHA) buildings subject to the policy and 11 privately managed buildings in which most residents received housing vouchers (herein “Section 8”). Aims and Methods We invited participants from nonsmoking households (NYCHA n = 157, Section-8 n = 118) to enroll in a longitudinal air monitoring study, measuring (1) nicotine concentration with passive, bisulfate-coated filters, and (2) particulate matter (PM2.5) with low-cost particle sensors. We also measured nicotine concentrations and counted cigarette butts in common areas (n = 91 stairwells and hallways). We repeated air monitoring sessions in households and common areas every 6 months, totaling six post-policy sessions. Results After 3 years, we observed larger declines in nicotine concentration in NYCHA hallways than in Section-8, [difference-in-difference (DID) = −1.92 µg/m3 (95% CI –2.98, −0.87), p = .001]. In stairwells, nicotine concentration declines were larger in NYCHA buildings, but the differences were not statistically significant [DID= −1.10 µg/m3 (95% CI −2.40, 0.18), p = .089]. In households, there was no differential change in nicotine concentration (p = .093) or in PM2.5 levels (p = .385). Conclusions Nicotine concentration reductions in NYCHA common areas over 3 years may be attributable to the SFH policy, reflecting its gradual implementation over this time. Implications Continued air monitoring over multiple years has demonstrated that SHS exposure may be declining more rapidly in NYCHA common areas as a result of SFH policy adherence. This may have positive implications for improved health outcomes among those living in public housing, but additional tracking of air quality and studies of health outcomes are needed. Ongoing efforts by NYCHA to integrate the SFH policy into wider healthier-homes initiatives may increase policy compliance.

Low-income communities often lack access to supermarkets and healthy foods. Enhanced stocking requirements for staple foods for Supplemental Nutrition Assistance Program (SNAP)-authorized retailers may increase availability of healthy foods in smaller stores which are prevalent in low-income areas. This study aimed to evaluate the extent that small food stores located in low-income areas met the U.S. Department of Agriculture's 2016 final rule on SNAP-authorized retailer stocking requirements, which increased the minimum number of required staple food varieties from three to seven for each staple food category, required a depth of stock of three units of each variety, and increased the required number of categories with perishables from two to three. A multisite research project was conducted in 2017. Nine research teams located in seven U.S. states audited the availability of perishable and nonperishable staple foods and beverages in 351 small food stores in low-income areas. Analyses determined the extent to which stores met all or part of the stocking requirements and tested differences by store type. 30.2% of stores met all of the 2016 final rule requirements; 86.3% met the requirements for fruits and vegetables, whereas only 30.5% met requirements for dairy. 53.1% of non-chain small grocery stores met all requirements compared to 17.1% of convenience stores (p < .0001). Less than one half of the food stores audited met the U.S. Department of Agriculture's 2016 final rule that would expand SNAP-authorized retailer stocking requirements suggesting that, if implemented, the rule may generate increased offerings of staple foods in small stores in low-income areas.

Structural Vector Autoregression (SVAR) methods suggest the monetary transmission mechanism may be weak and unreliable in many low-income African countries. But are structural VARs identified via short-run restrictions capable of detecting a transmission mechanism when one exists, under research conditions typical of low-income countries (LICs)? Using a small DSGE as our data-generating process, we assess the impact on VAR-based inference of short data samples, measurement error, high-frequency supply shocks, and other features of the LIC environment. The impact of these features on finite-sample bias appears to be relatively modest when identification is valid—a strong caveat, especially in LICs. Nonetheless many of these features undermine the precision of estimated impulse responses to monetary policy shocks, and cumulatively they suggest that statistically and economically insignificant results can be expected even when the underlying transmission mechanism is strong. These data features not only undermine the efficacy of the SVAR methodology for research and policy-making, but are also severe enough to motivate a continued search for monetary policy rules that are robust to these limitations.

Background Adults with low income have limited access to valuable health resources thus presenting a major obstacle to improving their health. Although there are diverse health enhancement programs for low-income populations, relatively few focus on emotional support despite the positive impact of perceived emotional support on health. This study examines the interaction of perceived emotional support and income on the overall health status and psychological well-being of adults with low income. Methods Secondary data were collected from the Health Information National Trends Survey (Cycle 4). A total of 3677 respondents completed the survey, including 889 adults with low income, as determined by their eligibility for the Supplemental Nutrition Assistance Program (SNAP). Ordinary-least square hierarchical regression analysis was conducted to test main and interaction effects. Results Perceived emotional support moderated the relationship between SNAP eligibility and health outcomes. Lacking an emotional support network has greater detrimental effects on the overall health and psychological well-being of people with low income compared to similar persons with higher income. Conclusion These findings suggest the need for health programs that enhance access to emotional support for adults with low income.

Background and Objectives Despite evidence linking financial challenges to poor health among older adults, effective interventions are lacking. This study examined the experience of living with financial challenges, useful strategies to handle them, and social norms that may constrain options and decision-making. Research Design and Methods This two-staged qualitative study recruited low-income older adults from the United States Baltimore City area. First, semistructured individual interviews examined older adults’ experiences and strategies used to handle financial challenges. Then, vignette-based focus groups examined relevant social norms. Transcripts were coded, and hierarchical themes were described using thematic analysis. Results Two themes were generated. First, the social norms relevant to financial challenges share a common underlying assumption of personal responsibility. Second, social norms about personal responsibility are inconsistent with the experiences of older adults facing financial challenges, who typically lack control over their situation and face structural barriers to preventing and handling financial challenges. Differences between statements related to norms and personal responsibility were found across six subthemes, including how finances should be handled to prevent financial challenges, the causes of financial challenges, asking for help from community resources, navigating community resources, getting help from family, and cutting back to handle financial challenges. Discussion and Implications The disconnect between social norms and the reality of financial challenges among older adults may explain why so many older adults cut back to the point of foregoing necessities. There is an urgent need to strengthen the social safety net and remove normative barriers to services.

Aims Elevated body mass index (BMI) is an important cause of cardiovascular disease (CVD). The population-level impact of pharmacologic strategies to mitigate the risk of CVD conferred by the metabolic consequences of an elevated BMI is not well described. Methods and results We conducted an analysis of 145 986 participants (mean age 50 years, 58% women) from 21 high-, middle-, and low-income countries in the Prospective Urban and Rural Epidemiology study who had no history of cancer, ischaemic heart disease, heart failure, or stroke. We evaluated whether the hazards of CVD (myocardial infarction, stroke, heart failure, or cardiovascular death) differed among those taking a cardiovascular medication (n = 29 174; including blood pressure-lowering, blood glucose-lowering, cholesterol-lowering, or anti-thrombotic medications) vs. those not taking a cardiovascular medication (n = 116 812) during 10.2 years of follow-up. Cox proportional hazard models with the community as a shared frailty were constructed by adjusting age, sex, education, geographic region, physical activity, tobacco, and alcohol use. We observed 7928 (5.4%) CVD events and 9863 (6.8%) deaths. Cardiovascular medication use was associated with different hazards of CVD (interaction P < 0.0001) and death (interaction P = 0.0020) as compared with no cardiovascular medication use. Among those not taking a cardiovascular medication, as compared with those with BMI 20 to Conclusion To the extent that CVD risk among those with an elevated BMI is related to hypertension, diabetes, and an elevated thrombotic milieu, targeting these pathways pharmacologically may represent an important complementary means of reducing the CVD burden caused by an elevated BMI.

Low-income mothers face disproportionately high risks of engaging with statutory child protection systems. Whilst this is often perceived as a result of poor or irresponsible parenting practices, an increasing body of scholarship foregrounds the role of structural issues—such as poverty and homelessness—that constrain mothers’ agency and impact their ability to care for their children. In this article, we examine Australia’s first permanent Supportive Housing for Families (SHF) programme, which offers low-income mothers practical resources to minimise the risk of statutory child protection intervention. Our research aims to understand low-income mothers’ willingness and ability to care for their children, and how mothers engaged with and made meaning of their experiences residing in SHF. Using a qualitative research design, we analyse interview data with programme mothers (n = 17), programme support workers (n = 10) and statutory child protection officers (n = 7). We find that the resources provided through the programme enabled mothers to care for their children in ways that aligned with their parenting beliefs and aspirations. We conclude that SHF programmes may be an effective means through which low-income mothers can overcome the structural barriers that keep them engaged with statutory child protection systems.

Context Online grocery services are an emerging component of the food system with the potential to address disparities in access to healthy food. Objective We assessed the barriers and facilitators of equitable access to healthy foods in the online grocery environment, and the psychosocial, purchasing, and dietary behaviors related to its use among low-income, diverse populations. Data Sources Four electronic databases were searched to identify relevant literature; 16 studies were identified. Results Barriers to equitable access to healthy food included cost and limited availability of online grocery services in food deserts and rural areas. The expansion of online grocery services and the ability to use nutrition assistance benefits online were equity-promoting factors. Perceived low control over food selection was a psychosocial factor that discouraged online grocery use, whereas convenience and lower perceived stress were facilitators. Findings were mixed regarding healthfulness of foods purchased online. Although few studies assessed diet, healthy food consumption was associated with online grocery use. Conclusion Researchers should assess the impact of online grocery shopping on low-income families’ food purchases and diet. Systematic Review Registration PROSPERO registration no. CRD: 42021240277

BackgroundCommunity surveillance for acute respiratory illness (ARI) can include unsupervised participant-collected nasal swabs. Little is known about use of self-swabs in low-income populations or among households including extended family members and the validity of self-collected swabs. We assessed the acceptability, feasibility, and validity of unsupervised participant-collected nasal swabs in a low-income, community sample.MethodsThis was a substudy of a larger prospective community-based ARI surveillance study in 405 households in New York City. Participating household members self-collected swabs on the day of a research home visit for an index case, and for 3–6 subsequent days. Demographics associated with agreement to participate and swab collection were assessed, and index case self-collected versus research staff–collected swab results were compared.ResultsMost households (n = 292 [89.6%]) agreed to participate, including 1310 members. Being ConclusionsSelf-swabbing was acceptable, feasible, and valid in this low-income, minoritized population. Some differences in participation and swab collection were identified that could be noted by future researchers and modelers.

ObjectiveAdolescents from low-income backgrounds are at increased risk for obesity and related negative health outcomes. Furthermore, these adolescents have less access to, and success in, weight management (WM) programs. This qualitative study sought to better understand engagement in a hospital-based WM program from the perspective of adolescents and caregivers at different levels of program initiation and engagement.MethodsQualitative interviews were conducted with 55 participants (29 adolescents and 26 caregivers). This included: (a) those that were referred to, but never initiated, WM treatment (non-initiators); (b) those that prematurely disengaged from treatment (drop-outs); and (c) those that had ongoing participation in treatment (engaged). Data were analyzed using applied thematic analysis.ResultsRelated to program initiation, participants across all groups (including adolescents and caregivers) noted that they did not have a full understanding of the scope or goals of the WM program following initial referral. In addition, many participants identified misperceptions of the program (e.g., perceptions of a screening visit as compared to an intensive program). Both caregivers and adolescents identified caregivers as drivers of engagement, with adolescents often hesitant about participation in the program. However, engaged adolescents found the program valuable and sought ongoing participation following caregiver initiation.ConclusionsWhen considering initiation and engagement in WM services for adolescents at highest risk, healthcare providers should provide more detailed information concerning WM referrals. Future research is needed to improve adolescent perception of WM, especially for adolescents from low-income backgrounds, which could increase initiation and engagement for this population.

Tetanus is a potentially severe but preventable infection. In resource-rich settings, vaccination programmes have reduced tetanus to a rare disease, though still carrying an overall mortality of some 13%. However, in low-income settings, tetanus remains common, and is a significant cause of mortality—though major World Health Organisation programmes are successfully targeting neonatal and maternal disease. Data concerning the frequency and outcomes of non-neonatal tetanus in low-income settings are very sparse. We aimed to utilize a unique intensive care unit-based dataset to elicit clinical and demographic features and mortality in a large cohort of tetanus patients admitted over an eleven-year period to a single hospital centre in a rural low-income setting in northern Uganda. A total of 268 patients with tetanus were admitted to the Intensive Care Unit at St Mary’s Hospital, Lacor between 2005 and 2015; the records of 190 were retrievable and had sufficient information to be assessed. 29 were neonates (median age 7 days, IQR 0), 52 children (1–16yrs; median age 11 years, IQR 4.5) and 109 were adults (median age 42 years, IQR 23). There was no seasonal pattern in the frequency of admissions. Of the 190 patients, 69 had endotracheal intubation with intermitent positive pressure ventilation, and 57 patients had central line placement. The overall mortality was 51.5–72.4% in neonatal disease, 25% in children and 57.8% in adults. The requirements for neither central line insertion, nor endotracheal intubation, nor intermittent positive pressure ventilation were independently linked to mortality rates. By contrast with neonatal and childhood disease, there was a marked male preponderance in adult tetanus—94 males and 15 females (gender difference P, Graphical Abstract Graphical Abstract, Tetanus is a severe but preventable infection. Olum et al. studied 190 tetanus admissions to one northern Uganda hospital. The overall mortality was 51.5%, with a marked male preponderance among adults—94 males versus 15 females. Their findings re-emphasise adult tetanus as a major problem in rural low-income settings.

Intra-cardiac retained bullets rare entities in clinical practice owing to the high mortality associated with it. We present a case of a 26-year-old male patient presented 24 days after sustaining a bullet injury to the left side of the chest. Intra-operatively totally myocardial bullet was found within the right ventricle and extracted successfully.

Background High out-of-pocket costs may impact anticancer treatment uptake. The Low-Income Subsidy (LIS) program can reduce patient out-of-pocket cost for Medicare Part D–covered treatments. We examined whether the LIS increased uptake and reduced time to initiate orally administered anticancer drugs in patients with advanced non–small cell lung cancer (NSCLC). Methods Using Surveillance, Epidemiology and End Results (SEER)-Medicare data, we identified older adults (aged 65 years and older) diagnosed with advanced NSCLC from 2007 through 2013 and categorized them as full LIS, partial LIS, or non-LIS. We used propensity-score weighted (IPTW) Cox proportional hazards regression to assess the likelihood of and time to initiate Part D treatments. Part B medication uptake was our negative control because supplemental insurance reduces out-of-pocket costs for those drugs. All statistical tests were two-sided. Results Among 19 746 advanced NSCLC patients, approximately 10% initiated Part D treatments. Patients with partial or no LIS were less likely to initiate Part D treatments than were those with full subsidies (partial LIS vs full LIS HRIPTW = 0.77, 95% confidence interval = 0.62 to 0.97; non-LIS vs full LIS HRIPTW = 0.87, 95% confidence interval = 0.79 to 0.95). Time to initiate Part D treatments was also slightly shorter among full-LIS patients (full LIS mean [SD] = 10.8 [0.04] months; partial LIS mean [SD] = 11.3 [0.08] months; and non-LIS mean [SD] = 11.1 [0.03] months, P < .001). Conversely, patients with partial or no LIS had shorter time to initiation of Part B drugs. Conclusions Patients receiving the full LIS had higher orally administered anticancer treatment uptake than patients without LIS. Notably, patients with partial LIS had the lowest treatment uptake, likely because of their low incomes combined with high expected out-of-pocket spending. High out-of-pocket costs for Part D medications may be a barrier to treatment use for patients without full LIS.

Introduction Healthy sleep is critical for child development, yet disparities exist, with Latino children disproportionately affected by deficient sleep. Most of what is known about sleep ecology and interventions to improve sleep in young children is based on studies of primarily White, non-Latino, and economically-advantaged families. To ensure the effectiveness of interventions, it is important to understand the contribution of socioecological factors on sleep among toddlers in low-income Mexican American families. Methods This study employed in-depth interviews with a purposeful sample of low-income Mexican American Spanish-speaking (n=10) and English-speaking mothers (n=10) of toddlers (18-34 months old). Interviews focused on daily sleep routines, perceptions of toddler sleep behaviors, and environmental contributors. Transcripts were coded by two investigators and analyzed using a content analytic approach. Results For sleep-related parenting practices, 70% of mothers reported late child bedtimes (≥9:00 pm), 75% reported room/bed sharing, and almost a third of children fell asleep at bedtime with a bottle or cup. Maternal beliefs about child sleep included concerns that child crying during the night might disturb neighbors or wake siblings, and child sleep quality improved when the child is not hungry. Contextual factors impacting sleep included schedules, neighbors, and siblings. Specifically, later weekday bedtimes were attributed to maternal (but not paternal) work schedules, while wake times were often a result of a sibling’s school schedule. Weekend bedtimes were commonly reported to be delayed for toddlers due to families watching movies. Noisy neighbors, in particular upstairs neighbors, were identified as disrupting children’s sleep. Siblings were identified as both facilitating sleep (e.g., helping with routines) and disrupting sleep (e.g., distracting child at nap time). Conclusion Findings provide insights on socioecological factors and parental beliefs about sleep ecology in low-income Mexican American toddlers that have implications for the design of interventions to improve child sleep. For example, commonly used behavioral sleep interventions have children sleeping in their own room, or require some crying during the night. However, these approaches may not be a good fit or feasible for this population. To address sleep health disparities, further work is needed to understand socioecological factors that require inclusive adaptations to pediatric sleep interventions. Support (if any) R01HL163859

Non-communicable diseases and associated risk factors, such as obesity, are prevalent and increasing in Malaysia. To address this burden and the heightened vulnerability of low-income communities to these risk factors, the Better Health Programme Malaysia conducted a partial-profile discrete choice experiment (DCE) to inform the design of a community-based obesity-prevention programme. The DCE survey was conducted with community members (n = 1453) from three publicly supported low-cost, high-rise flat complexes in urban Kuala Lumpur. In the survey, community members were asked to choose between different sets of potential evidence-based interventions for obesity prevention. Their responses to these choice tasks were analysed to quantify preferences for these different health interventions using a random utility maximization model. Based on these results, we determined participants' relative prioritization of the different options. The most preferred interventions were those that reduced the price of fruit and vegetables; altered cooking practices at restaurants and food vendors to reduce salt, sugar and oil; and offered reward incentives for completing online educational activities. Community members did not prioritize several evidence-based interventions, including changes to product placement or product labelling, suggesting that these effective approaches may be less familiar or simply not preferred by respondents. The DCE enabled the clear articulation of these community priorities for evidence-based interventions that focus on the supply and promotion of affordable healthy foods within the local food environment, as well as community demand for healthier food options.Non-communicable diseases (NCDs) and the factors that increase NCD risk, such as obesity, are widespread and increasing in Malaysia. Low-income communities are particularly vulnerable to these risk factors. The Better Health Programme (BHP) Malaysia conducted a discrete choice experiment (DCE) to elicit community member preferences for evidence-based health promotion interventions to prevent obesity and NCDs. DCE is a research method used to identify participant preferences between different pre-determined options. The DCE survey was conducted with community members (n = 1453) from three publicly supported low-cost, high-rise flat complexes in urban Kuala Lumpur. In the survey, community members were asked to choose between different potential sets of interventions to alter the environment to prevent obesity. Based on their responses, we determined which interventions were most preferred in each community. The most preferred interventions were those that reduced the price of fruit and vegetables; altered cooking practices at restaurants and food vendors to reduce salt, sugar and oil; and offered rewards for completing online educational activities. The survey enabled the clear articulation of these community priorities for evidence-based interventions. These priorities were used to design the BHP Malaysia intervention programme.

Aim Minimal invasive repair is now the established procedure for ventral hernia. Surgeons are now validating newer techniques each year to deal with the ventral hernia. It becomes difficult to choose, best fit technique from this large armamentarium. For a low income country like India, ventral- trans abdominal preperitoneal (TAPP) technique is cost effective and uses simple polyester or polypropylene mesh. Methods For this article we used our experience with ventral-TAPP performed from July 1, 2021 to May 31, 2022. Patients were followed up for 6 months. Results In the above time period, we had performed 10 ventral-TAPP. Out of these, 3 had completed the follow up. Median age was 45.0 years, BMI was 26.56 kg/m2. One patient was male (33.33%). All patients were presented to surgery due to bulge or pain in the anterior abdominal wall. The median hernia defect measured 80 mm, median mesh diameter was 15 cm and median operative time was 125 min. No intraoperative complications occurred. Postoperatively, none of the patients developed complications. Length of hospital stay was 3.0 days. Six months after surgery, neither recurrence nor chronic pain were recorded. Conclusion We have concluded that mesh used in repair with ventral-TAPP costs one fourth to one-fifth to that of composite mesh used in intraperitoneal onlay mesh (IPOM) repair with the comparable results. So in a low income country like India, ventral TAPP should be a preferred approach.

Introduction The competing neurobehavioral decision systems theory conceptualizes addictive behavior, such as cigarette smoking, as arising from the imbalance between stronger impulsive relative to weaker executive decision processes. Working memory trainings may enhance executive decision processes, yet few studies have evaluated its efficacy on substance misuse, with mixed evidence. The current study is the first to evaluate the efficacy of a working memory training on cigarette smoking. We consider the moderating role of delay discounting (DD), or the preference for smaller, immediately available rewards relative to larger, delayed rewards, which has been associated with smoking onset, progression, and resumption. The investigation focuses on individuals living in high-poverty, low-resource environments due high burden of tobacco-related disease they experience. Aims and Methods The study utilized a subset of data (N = 177 individuals who smoke) generated from a randomized clinical trial that is evaluating the efficacy of working memory training for improving health-related outcomes. Participants were randomized to complete up to 15 sessions of the active, working memory training or a control training. Results Findings showed that among participants who were randomized to the working memory condition, those with higher rates of baseline DD demonstrated decreases in cigarette smoking (p = .05). Conversely, individuals randomized to the control condition, who had higher rates of baseline DD exhibited increases in cigarette smoking (p = .025). Conclusions Results suggest that DD may be an important indicator of working memory training outcomes and a possible approach for effectively targeting treatments in the future. Implications DD is important indicator of working memory training outcomes on cigarette smoking. The findings suggest the possibility to effectively target treatments considering the impact of DD. Given that rates of DD tend to be higher among individuals from low-resource communities, and that computer-based working memory training programs are relatively low-cost and scalable, these findings suggest this approach may have specific utility for adults at heightened risk for cigarette use. This study was registered with ClinicalTrials.gov (Identifier NCT03501706).

Background Inequalities in obesity and related non-communicable diseases pertain in part to less healthy dietary intake in disadvantaged groups. Examining determinants of intake as a complex adaptive system - i.e. interconnected determinants exerting non-linear influence on outcomes - honours the complexity of dietary choices, behaviours and intake, and could inform policies. This study used literature to map the complex system underlying dietary intake in low-income groups, to identify system structure and goals perpetuating poorer dietary outcomes. Methods A systematic umbrella literature review examined determinants of dietary outcomes in children, adolescents and adults. Inclusion criteria were: • Low-income sample; analysis by income (Non-)systematic review of quantitative/qualitative, observational/intervention studiesHigher/upper-middle-income countriesExposures: individual, sociocultural, physical, political determinants/correlates; effect modifiers Excluded outcomes were: breastfeeding, alcohol and neophobia. Using causal loop diagramming, extracted data on determinants, associations and interpretation were embedded in a systems map of mechanisms driving dietary intake. System structure (e.g. sub-systems) and goals (e.g. feedback loops) were analysed. Results A systems map of hypothesised mechanisms driving dietary intake in low-income groups was developed from 43 reviews and expert consensus. The system comprised sub-systems: 1) accessibility, 2) household resources, 3) financial constraints, 4) health/biology, 5) knowledge, attitudes and beliefs, 6) sociocultural influences. Identified sub-system goals could undermine healthy intake opportunities, e.g. energy-dense food choices for cost-efficiency, heightened exposure to energy-dense foods determining preferences. Conclusions The literature-based systems map articulates the systemic basis of poorer dietary outcomes in low-income groups. Understanding system structure and goals will inform equitable policy. Key messages Dietary intake in low-income groups is driven by a complex system of mechanisms which may perpetuate poorer dietary outcomes. Existing literature was synthesised as a systems map; identification of structures and goals of the system can inform health equity policies.

Author(s): McCredie, Victoria A; Shrestha, Gentle S; Acharya, Subhash; Bellini, Antonio; Singh, Jeffrey M; Hemphill, J Claude; Goffi, Alberto | Abstract: BackgroundThe Emergency Neurological Life Support (ENLS) is an educational initiative designed to improve the acute management of neurological injuries. However, the applicability of the course in low-income countries in unknown. We evaluated the impact of the course on knowledge, decision-making skills and preparedness to manage neurological emergencies in a resource-limited country.MethodsA prospective cohort study design was implemented for the first ENLS course held in Asia. Knowledge and decision-making skills for neurological emergencies were assessed at baseline, post-course and at 6 months following course completion. To determine perceived knowledge and preparedness, data were collected using surveys administered immediately post-course and 6 months later.ResultsA total of 34 acute care physicians from across Nepal attended the course. Knowledge and decision-making skills significantly improved following the course (p=0.0008). Knowledge and decision-making skills remained significantly improved after 6 months, compared with before the course (p=0.02), with no significant loss of skills immediately following the course to the 6-month follow-up (p=0.16). At 6 months, the willingness to participate in continuing medical education activities remained evident, with 77% (10/13) of participants reporting a change in their clinical practice and decision-making, with the repeated use of ENLS protocols as the main driver of change.ConclusionsUsing the ENLS framework, neurocritical care education can be delivered in low-income countries to improve knowledge uptake, with evidence of knowledge retention up to 6 months.

The aims of this study were: (1) to identify the determinants of unmet need for access to primary care in middle-aged and older adults; and (2) to examine the reasons for unmet need. We used data from the Canadian Longitudinal Study on Aging (CLSA), a nationally representative survey of adults aged 45 to 85 years. Respondents were asked if they ‘needed health care during the last 12 months but did not receive it’. For those who replied ‘Yes’, the survey asked for the reason(s) for not receiving the needed care. Out of 41,135 respondents, 3,468 had unmet need for healthcare in the last 12 months. Among respondents with 0, 1, 2 and ≥3 morbidities, the proportion reporting unmet need was 2.5%, 5.3%, 5.1% and 9.1% respectively. After adjusting for covariates, the odds ratios (ORs) for unmet need for 1, 2 and ≥3 morbidities (compared to no morbidity) were 1.25 (95% CI: 0.87 to 1.78; p = 0.23), 1.57 (95% CI: 1.13 to 2.17; p < 0.05) and 2.03 (95% CI: 1.51 to 2.73; p < 0.05), respectively. For income groups, the ORs for unmet need (compared to >$150,000/year) were 0.94 (95% CI: 0.79 to 1.12) for $100,000-$150,000, 1.02 (95% CI: 0.87 to 1.20;) for $50,000-$100,000, 1.30 (95% CI: 1.09 to 1.55) for $20,000-$50,000, and 1.39 (95% CI: 1.08 to 1.78) for < $20,000. Other statistically significant determinants of unmet need included age (older adults were less likely to have unmet need), sex (females were more likely), having a family physician (less likely) and perceived physical and mental health (poor health more likely to be associated with unmet need). The most common reasons for unmet need were: ‘long wait time’ (52.1%) and ‘doctor did not think it was necessary’ (16.7%). Multimorbidity and low-income are associated with higher odds of unmet need among older adults. This disparity is partly due to not having a regular family physician and long wait time to see a doctor. Reducing these barriers are critical to reducing inequalities in health outcomes.

Background The Healthy Start programme is a statutory benefit-in-kind in the United Kingdom (UK) which aims to enable low-income families to purchase fruit, vegetables, cow's milk and infant formula through the provision of vouchers. The scheme was introduced in 2006, however, the effect on food purchasing in participating households has not been evaluated within an eligible population. This study aimed to determine whether participation in the Healthy Start (HS) scheme is associated with differences in food purchasing in a representative sample of households in the United Kingdom. Methods Cross-sectional analysis of the Living Costs and Food Survey dataset (2010-2017). All households with a child (0-3 years) or pregnant woman were included in the analysis (n = 4,869). Multivariable quantile regression was used to compare the expenditure and quantity of fruit and vegetable, infant formula and total food purchases between Healthy Start participating, eligible non-participating, nearly-eligible and ineligible households. Results 54% (n = 475) of eligible households participated in Healthy Start. After accounting for covariates, no significant difference was found in the quantity or expenditure of fruit and vegetable purchases between Healthy Start participating and non-participating households. Fruit and vegetable expenditure (£/week) was found to be higher in nearly eligible (β1.60; 95% CI 0.79, 2.41) and ineligible households (β2.56; 95% CI 1.77, 3.35) compared to Healthy Start eligible households. Conclusions The present study did not demonstrate significant differences in the fruit and vegetable expenditure of HS participating and non-participating households. The analysis demonstrates that inequalities in fruit and vegetable purchasing persists in the UK. Improved participation and increased voucher value may be needed to promote well-being and counteract the harmful effect of poverty on fruit and vegetables purchasing. Key messages The study found no evidence of different food purchases between Healthy Start participating and non-participating households. Increased voucher value may be needed to counteract food-price inflation. The paper reflected persistent socioeconomic inequalities in the UK, indicating the Healthy Start scheme does not sufficiently counteract the harmful effects of poverty on food purchasing.

Issue In 2018, the mortality due to cervical cancer rose by 6.9 compared to the previous year, with 311.365 deaths in total. By 2030, it is estimated that there will be a 21.3% increase in incidence and 26.7% in mortality. In Colombia, cervical cancer is the second cause of death by cancer in women. Description of the Problem We present the design process of innovative prototypes for cervical cancer prevention in primary care centers located in low-income settings in Cali, Colombia, using the Human-Centered Design (HCD) approach. The practice was developed in collaboration with a public healthcare network comprised of 38 urban and rural centers with women between the ages of 25 and 65 years, healthcare providers of the cancer program, healthcare managers. We conducted five HCD stages: research, need synthesis, ideation and co-design process, prototyping and in-context usability testing. We used observations, open-ended interviews and conversations, multi-stakeholder workshops, focus groups, systematic text condensation analyses and tests in real contexts. Results We designed four prototypes: (1) 'Encanto': An educational manicure service, (2) 'No le des la espalda a la citología': A media-based strategy, (3) An educational wireless queuing device in the waiting room, and (4) Citobot: A cervical cancer early detection device, system, and method. Lessons The tests carried out with each prototype showed their value, limitations and possibilities in terms of subsequent development and validation through public health research or clinical research. We recognize that a longer-term evaluation is required in order to determine whether the prototypes will be used regularly, integrated into cervical cancer screening services and effectively improve access to cytology as a screening test. Key messages HCD is a useful methodology for design-based prevention in the field of cervical cancer. Integration of HCD with public health practice would allow the generation of evidence prior to the formulation of policies and programs as well as optimize existing interventions.

About 250 million children under age five are at risk of not reaching their developmental potential due to continued exposure to ill health, malnutrition and lack of appropriate learning environments. A large number of initiatives have been launched in recent years to support early childhood development, with home visiting programs increasingly being recognized as a key strategy for improving child wellbeing. However, the most effective ways to reach families in low income settings remain unclear due to the large expense associated with personal family visits. In this project, we assess the effectiveness and equity of a newly developed digital platform designed to deliver evidence-based, individualized parenting support through automated services. The Afinidata platform uses state-of-the art machine learning algorithms to allow caregivers to get answers to questions about child health and development, while also identifying and promoting age- and development-appropriate activities for parents to support their children. We will collaborate with partners in Peru to rigorously assess the reach, impact and cost effectiveness of this digital platform in a poor rural population through a randomized controlled trial. Our work will follow a mixed-methods evaluation approach with repeated feedback into the Afinidata system. A total of 2,400 newborns will be enrolled in a randomized controlled trial in San Marcos, Peru, and followed up for two years. The primary study outcome will be children's healthy development at 24 months of age assessed through the Bayley Scales of Infant and Toddler Development (BSID-III). Secondary outcomes will be systems utilization, program coverage and cost-effectiveness, as well as caregiver satisfaction. If proven effective, this innovative digital platform may increase global access to low-cost parental support -a widely recognized key strategy for improving child well-being.

BackgroundNoroviruses are the most common cause of epidemic and endemic acute gastroenteritis (AGE) worldwide. The burden of norovirus disease in low-income settings is poorly understood.MethodsWe tested stool samples from children less than 5 years of age with diarrhea who were admitted in a rural hospital in Bangladesh from 2010–2012 and from matched, healthy controls from the same catchment area.ResultsNorovirus was detected in 109 (18%) of 613 children with diarrhea and in 30 (15%) of 206 healthy controls. Most (n = 118; 85%) norovirus infections belonged to genogroup II (GII). Of these, GII.4 viruses were identified in 36 (33%) of the cases and in 6 (21%) of the controls. Other major genotypes included GII.3 (13%), GII.6 (11%), and GII.13 (11%) in the cases and GII.6 (17%) and GII.2 (14%) in the controls. The greatest risk of severe norovirus disease (Vesikari score ≥11) was associated with GII.4 infections. GII.4 viruses were the predominant genotype detected during the winter (55%) and rainy season (23%), while GII.3 (19%) and GII.13 (19%) viruses were the most prevalent genotypes during the summer. Vomiting was significantly associated with GII.4 infections, while longer durations of diarrhea were associated with GI.3 infections.ConclusionsFuture studies are needed to understand the high rates of virus shedding in children without AGE symptoms.

This research evaluated a community-led participatory planning process that sought to involve citizens who are often marginalized within planning processes. Participatory planning – which is theoretically informed by communicative planning theory – may shift the legacy of power and marginalization within planning processes and improve planning outcomes, foster social cohesion, and enhance the quality of urban life. The two-year Stewart Street Active Neighbourhoods Canada (ANC) project aimed to build capacity among residents of a low-income neighbourhood in Peterborough, Ontario and to influence City planning processes impacting the neighbourhood. The project, led by a community-based organization, GreenUP, fostered collaborative interactions between residents and planning experts and supported residents to build and leverage collective power within planning processes. The participatory planning approach applied in the Stewart Street ANC transformed – and at times unintentionally reproduced – inequitable power relations within the planning process. Importantly, we found that GreenUP was a vital power broker between marginalized residents and more formal power holders, and successfully supported residents to voice their collective visions within professionalized planning contexts.

Background Bacterial culture is the gold standard for the diagnosis of invasive bacterial diseases (IBDs) but molecular methods are more specific and sensitive. Fresh liquid samples (FLSs) show patent limitations for shipping and storage. We aimed to evaluate the sensitivity and specificity of real-time polymerase chain reaction (PCR) performed on dried sample spots (DSSs) obtained from different biological fluids compared with real-time PCR or culture performed on FLSs. Methods FLSs positive for Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae, Escherichia coli, Streptococcus pyogenes, Staphylococcus aureus, Bordetella pertussis and/or Pseudomonas aeruginosa were spotted on filter paper. Real-time PCR was performed on both FLSs and DSSs and results were compared. The stability of the DSS results over time was evaluated. Results Real-time PCR performed on 114 DSSs showed a specificity of 99.1% and a sensitivity of 91.2% for IBD diagnosis. A positive correlation was found between FLS cycle threshold (Ct) and DSS Ct (r=0.84; r2=0.71) with the Pearson statistical test and Bland–Altman analysis showing that 95% of the specimens were within agreeable limits. Although we observed a trend towards signal reduction over time in the DSSs, there was no statistical evidence of an increase in Ct values. Real-time PCR on DSSs was 2.2 times more sensitive than culture. Conclusions Real-time PCR applied to DSSs may be a useful approach in different situations, such as IBD diagnosis, both for rural areas of low-income countries and family practitioners in various settings.

Background and Aims During the last decade, the development of kidney transplantation in the Republic of Moldova took a new course due to the adoption of the new transplantation law, and was strongly marked by the first transplant from a brain death donor. The implementation of a transparent organ allocation policy, the development of donation after brain death and the upgrade of the transplant infrastructure, based on European good practices, are the strengths of the new program. Method Since 2014, all the kidney grafts from deceased donors have been allocated based on the electronic allocation system (Renal Score), which includes the following variables: compatibility in ABO and HLA systems, dialysis vintage, time on waiting list, renal graft accessibility score, age difference between recipient and donor. All the living donors were evaluated based on a National Protocol. This is a retrospective analysis of the kidney transplant program during a period of five years, focused on recipient and donor demographics, donor-recipient matching, medical outcomes. Results During 2014-2018, there were performed 75 kidney transplantations: 23 (30,7%) from living donors and 52 (69,3 %) from brain-death donors. Among the kidney transplant recipients, there were 24 women (32,4%) and 50 men (67.6%). From 23 living kidney donors there were 10 (43,5%) males and 13 (56,5%) females, 21 (91,3%) were related donors and 2 (8,7%) emotionally related. The mean age of living donors was 50,45, ranging from 23 to 67, with 6 donors (20,1%) older than 60 years old. During this period, from 110 evaluated potential brain death donors 48 (43,6%) became effective brain-death donors and kidneys were procured in 36 (75%) cases (from 15 men (41,7%) and 21 women (58,3%)). The mean recipients age was 41,13, ranging from 23 to 67, while the mean donor age was 54,72, ranging from 19 to 72 years old. 18 donors (50%) were older than 60, the mean age of male donors were 49,4 and 59,14 for female donors. The mean donor-recipient age difference was 17,09 years (min- 0, max- 40). The mean cold ischemia time was 17,31 hours, with a minimum of 6,33 hours and a maximum of 25,8 hours. The majority of donors were blood type 0- 14 (38.8%) and A-13 (36,1%) and only 6 donors (16.6%) blood type B and 3 (8.3%) type AB. Regarding the outcomes, we noticed a rate of delayed graft function in 43,6% cases, 2,6% of slow graft function and 53,9% recipients with immediate graft function Conclusion Despite social and economic challenges in our country, the joint efforts of the kidney transplant team, the Transplant Agency and the government support ensure a growing kidney transplant program. The strengths of our program are the good legal framework and the respect for the main ethical and medical principals: transparency and traceability, ensured by the informational platform, equity and utility ensured by the use of the automated allocation system, accessibility ensured by the fool coverage of transplant related services by the public health insurance. We still face many challenges, as the high rate of marginal donors compared to younger recipients and donor-recipient age disparities, a long cold ischemia time and a sub-optimal organ discard rate, which is mainly due to the shortage of transplant professionals, the direct effect of the migration of health care personnel. Our next goal is to identify and to improve the factors impacting on kidney graft outcomes in order to achieve better results.

Individuals demonstrate varying levels of Alzheimer’s disease (AD) knowledge, as well as commonly held misconceptions about the risk factors and nature of the disease. Older adults often demonstrate low scores on AD knowledge scales and African Americans are often specifically not aware of their higher AD risk status compared to other racial groups. We measured the Alzheimer’s knowledge in 60+ community-dwelling adults, as part of a larger study on AD health coaching. Participants (n=20) were recruited from low-income communities within the Richmond, Virginia area. The study sample was 85% African American (n=17) and 55% male (n=11). Participants completed a behavioral psychosocial test battery, including the Alzheimer’s Disease Knowledge Scale. Similar to previous research, this sample of older adults held common misconceptions about AD, including the ideas that mental exercise can prevent AD (80% answered incorrectly) and individuals with AD are incapable of making decisions about their care (70% answered incorrectly). In this sample, the majority of African American older adults were aware of the fact that they have the highest risk for developing AD (20% answered incorrectly) compared to other racial groups. Analyses found no significant relationship between AD knowledge and health outcomes, alcohol consumption, or education. In conclusion to reduce AD risk, addressing AD knowledge in minority low-income population is important and needed. This is especially relevant since African American older adults are more likely to live in communities rather than nursing or assisted living facilities, receiving less access to interventions and research innovation.

Aim The COVID-19 pandemic has adversely affected medical education and training programmes worldwide. This study aims to assess the impact of COVID-19 pandemic on surgical education and training in a low-income country. Method This cross-sectional study was conducted in Allied hospitals of Rawalpindi Medical University, Rawalpindi, Pakistan, from June 2021 to July 2021. A structured questionnaire designed by the researchers was distributed to all surgery departments, and surgical residents who consented to participate in this study were included. Data was analyzed using IBM SPSS v25. Results A total of 152 residents participated in this study, of which 53 (34.9%) were in general surgery and 99 (65.1%) in various surgical allied specialties. A large number of respondents reported a severe to complete reduction of elective surgical procedures (78, 51.3%), outpatient clinical activity (54, 35.6%) and academic sessions (86, 56.6%). A significantly higher number of general surgery residents (52.8%) reported increase in emergency surgical procedures as compared to surgical allied specialties (35.4%) (P=0.037). Majority of the respondents believed that loss of surgical training opportunities had a negative impact on their training and job performance (127, 83.6% and 130, 85.5%, respectively) with 43 (28.3%) residents suggesting an extension in training program. 137 (90.1%) residents reported increased stress and anxiety levels with the number of surgical allied residents significantly higher than general surgery residents (P=0.031). 125 (82.2%) respondents claimed that fear of contracting the virus affected proper patient evaluation. Conclusions COVID-19 pandemic has severely impacted the training and psychological wellbeing of surgical residents and drastically affected patient evaluation.