Search

Background: This is the final of 10 papers that describe the implementation of the Expanded Census-Based, Impact-Oriented Approach (CBIO+) by Curamericas/Guatemala in the Cuchumatanes mountains of the Department of Huehuetenango and its effectiveness in improving the health and well-being of women and children in a population of 98,000 in three municipalities. The CBIO+ Approach consists of three components: the CBIO (Census-Based, Impact-Oriented) Approach, the Care Group Approach, and the Community Birthing Center Approach. Methods: Each of the preceding papers was summarized. An assessment was made regarding the degree to which the initial implementation research hypotheses were confirmed. The total field cost per capita for operation of the Project was calculated. An assessment of the cost-effectiveness of the Project was made based on the estimated impact of the Project, the number of lives saved, and the number of disability-adjusted life years averted. Results: The Project attained a number of notable achievements in terms of expanding the coverage of key maternal and child health interventions, improving the nutritional status of children, reducing the mortality of children and mothers, providing quality care for mothers at the Community Birthing Centers (Casas Maternas Rurales) that integrate traditional midwives (comadronas) into the care of women during childbirth at the birthing centers, as well as empowering women and building social capital in the communities. CBIO+ is an effective and affordable approach that is particularly notable for its capacity to engage communities in the process of improving the health of mothers and children. Overall, there is strong and consistent evidence in support of the research hypotheses. The findings did produce evidence of declines in under-5 and maternal mortality, but they were not as robust as had been hoped. Conclusion: CBIO+ is an approach that has been effective in engaging communities in the process of improving the health of their mothers and children and in reducing health inequities in this marginalized, difficult-to-reach population of Indigenous Maya people. The CBIO+ Approach is cost-effective and merits further development and broader application in Guatemala and beyond. [ABSTRACT FROM AUTHOR]

While the health of and healthcare use by migrants has received significant scholarly and policy attention in Australia, current debates highlight that a critical examination of the theoretical underpinnings of these inquiries and responses is needed. We conducted a systematic review and critical interpretive synthesis (CIS) to critically examine how the policy and scholarly literature conceptualises migrants' interactions with and experiences of the Australian health system. Guided by PRISMA, we searched for literature without imposing any limits. We also searched key State and Federal Government websites for relevant policy documents. Our initially broad inclusion criteria became refined as the CIS progressed. We prioritised the likely relevance and theoretical contribution of the papers to our inquiry over methodological quality. The CIS of 104 papers revealed that the Australian scholarly literature and policy documents consistently homogenise and reduce migrants according to an assumed, (1) cultural identity, (2) linguistic affiliation, and/or (3) broad geographic origin. Based on these three critiques and drawing on the theoretical literature, we propose a synthesising argument on how the Australian literature could better conceptualise migrants' experiences of the Australian health system. We contend that both research and policy should explicitly recognise and engage with the multifaceted and shifting ways that migrants define themselves, generally, and during their encounters with destination country health systems. Engagement with this notion is necessary for also understanding how aspects of migrants' identities are dynamically co-constructed during their interactions with the health system. These understandings have implications for improving the design and implementation of policies and programs directed at improving the responsiveness of Australia's health system to the needs and expectations of migrant communities specifically, and destination countries broadly. [ABSTRACT FROM AUTHOR]

Background: Persons with albinism face challenges to their wellbeing, safety, and security, ranging from vision impairment and skin cancer to stigma and discrimination. In some regions, they also face human rights atrocities including mutilation and murder. Research on human rights and albinism is a relatively new field that has gained momentum since the United Nations appointment of an Independent Expert on the enjoyment of human rights by persons with albinism. In this paper, we present the results of a mixed methods study undertaken to identify priorities for research, advocacy, and policy on albinism and human rights., Methods: The first component was a synthesis of peer-reviewed and grey literatures at the nexus of albinism, spiritual/cultural beliefs and practices, and human rights. We then conducted a priority-setting survey, informed by Delphi methods, on extant knowledge-practice gaps and research, advocacy, and policy priorities. Inclusion criteria included demonstrated expertise in the field (e.g., peer-reviewed publications, funded research), membership on national or international associations, or advocacy (civil society organizations) of more than 2 years in albinism and human rights. Thereafter, we gathered leading researchers, policy-makers, and civil society stakeholders for a Roundtable to gain consensus on these priorities., Results: Access to skin and vision care, and education were not deemed high priority for research, likely because the evidence supporting the need for these is well established. However, they were priorities for advocacy and policy: what is needed is mobilization of this evidence through advocacy and implementation of such services (policy). Other social determinants of health (rurality, poverty, and gender equality) are present as subtext in the findings, more so than priorities for research, advocacy, or policy, despite their preponderance in the lives of persons with albinism. Research was prioritized on stigma and discrimination; advocacy; and witchcraft, but with some differentiation between Global North and Global South priorities. Priorities for research, advocacy, and policy vary in keeping with the explanatory frameworks at play, including how harmful practices and witchcraft are viewed., Conclusions: The lived experience of albinism is profoundly shaped by the social determinants of health (SDOH). Threats to the security and well-being of persons with albinism should be viewed through a human rights lens that encompasses the explanatory frameworks at play., (© 2023. The Author(s).)

Context: The COVID-19 pandemic has reignited a commitment from the health policy and health services research communities to rebuilding trust in healthcare and created a renewed appetite for measures of trust for system monitoring and evaluation. The aim of the present paper was to develop a multidimensional measure of trust in healthcare that: (1) Is responsive to the conceptual and methodological limitations of existing measures; (2) Can be used to identify systemic explanations for lower levels of trust in equity-deserving populations; (3) Can be used to design and evaluate interventions aiming to (re)build trust. Methods: We conducted a 2021 review of existing measures of trust in healthcare, 72 qualitative interviews (Aug-Dec 2021; oversampling for equity-deserving populations), an expert review consensus process (Oct 2021), and factor analyses and validation testing based on two waves of survey data (Nov 2021, n = 694; Jan-Feb 2022, n = 740 respectively). Findings: We present the Trust in Multidimensional Healthcare Systems Scale (TIMHSS); a 38-item correlated three-factor measure of trust in doctors, policies, and the system. Measurement of invariance tests suggest that the TIMHSS can also be reliably administered to diverse populations. Conclusions: This global measure of trust in healthcare can be used to measure trust over time at a population level, or used within specific subpopulations, to inform interventions to (re)build trust. It can also be used within a clinical setting to provide a stronger evidence base for associations between trust and therapeutic outcomes. [ABSTRACT FROM AUTHOR]

Background and objective: On the trajectory towards universal health coverage in Bhutan, health equity requires policy attention as significant disparities exist between urban and rural health outcomes. This paper examines health services utilization patterns, inequalities and their socio-economic determinants in rural and urban areas and decomposes the factors behind these differences. Methods: We used the Bhutan Living Standard Survey 2017 to profile health services utilization patterns and equalities. We employed two different decomposition analyses: decomposition of mean differences in utilization using the Oaxaca–Blinder decomposition framework and differences in the income-related distribution in utilization using recentered influence function regressions between rural and urban areas. Results: Significant differences exist in the type of outpatient services used by the rural and urban population groups, with those living in rural areas having 3.4 times higher odds of using primary health centers compared to outpatient hospital care. We find that the use of primary health care is pro-poor and that outpatient hospital resources is concentrated among the more affluent section of the population, with this observed inequality consistent across settings but more severe in rural areas. The rural–urban gap in utilization is primarily driven by income and residence in the eastern region, while income-related inequality in utilization is influenced, aside from income, by residence in the central region, household size, and marriage and employment status of the household head. We do not find evidence of significant mean differences in overall utilization or inequality in utilization of inpatient health care services. Conclusions: While the differences in average contacts with health services are insignificant, there are prominent differences in the level of services availed and the associated inequality among rural and urban settings in Bhutan. Besides, while there are obvious overlaps, factors influencing income-related inequality are not necessarily the same as those driving the utilization gaps. Cognizance of these differences may lead to better informed, targeted, and potentially more effective future research and policies for universal health coverage. [ABSTRACT FROM AUTHOR]

Background: Gender equality remains an outstanding global priority, more than 25 years after the landmark Beijing Platform for Action. The disconnect between global health policy intentions and implementation is shaped by several conceptual, pragmatic and political factors, both globally and in South Africa. Actor narratives and different framings of gender and gender equality are one part of the contested nature of gender policy processes and their implementation challenges. The main aim of this paper is to foreground the range of policy actors, describe their narratives and different framings of gender, as part exploring the social construction of gender in policy processes, using the Adolescent Youth Health Policy (AYHP) as a case study. Methods: A case study design was undertaken, with conceptual underpinnings combined from gender studies, sociology and health policy analysis. Through purposive sampling, a range of actors were selected, including AYHP authors from government and academia, members of the AYHP Advisory Panel, youth representatives from the National Department of Health Adolescent and Youth Advisory Panel, as well as adolescent and youth health and gender policy actors, in government, academia and civil society. Qualitative data was collected via in-depth, semi-structured interviews with 30 policy actors between 2019 and 2021. Thematic data analysis was used, as well as triangulation across both respondents, and the document analysis of the AYHP. Results: Despite gender power relations and more gender-transformative approaches being discussed during the policy making process, these were not reflected in the final policy. Interviews revealed an interrelated constellation of diverse and juxtaposed actor gender narratives, ranging from framing gender as equating girls and women, gender as inclusion, gender as instrumental, gender as women's rights and empowerment and gender as power relations. Some of these narrative framings were dominant in the policy making process and were consequently included in the final policy document, unlike other narratives. The way gender is framed in policy processes is shaped by actor narratives, and these diverse and contested discursive constructions were shaped by the dynamic interactions with the South Africa context, and processes of the Adolescent Youth Health Policy. These varied actor narratives were further contextualised in terms of reflections of what is needed going forward to advance gender equality in adolescent and youth health policy and programming. This includes prioritising gender and intersectionality on the national agenda, implementing more gender-transformative programmes, as well as having the commitments and capabilities to take the work forward. Conclusions: The constellation of actors' gender narratives reveals overlapping and contested framings of gender and what is required to advance gender equality. Understanding actor narratives in policy processes contributes to bridging the disconnect between policy commitments and reality in advancing the gender equality agenda. [ABSTRACT FROM AUTHOR]

Introduction: International organisations have called to increase young people's involvement in healthcare and health policy development. We currently lack effective methods for facilitating meaningful engagement by young people in health-related decision-making. The purpose of this scoping review is to identify deliberative priority setting methods and explore the effectiveness of these in engaging young people in healthcare and health policy decision-making. Methods: Seven databases were searched systematically, using MeSH and free text terms, for articles published in English before July 2021 that described the use of deliberative priority setting methods for health decision-making with young people. All titles, abstracts and full-text papers were screened by a team of six independent reviewers between them. Data extraction followed the Centre for Reviews and Dissemination guidelines. The results are presented as a narrative synthesis, structured around four components for evaluating deliberative processes: 1) representation and inclusion of diverse participants, 2) the way the process is run including levels and timing of participant engagement, 3) the quality of the information provided to participants and 4) resulting outcomes and decisions. Findings: The search yielded 9 reviews and 21 studies. The more engaging deliberative priority setting tools involved young people-led committees, mixed methods for identifying and prioritising issues and digital data collection and communication tools. Long-term and frequent contact with young people to build trust underpinned the success of some of the tools, as did offering incentives for taking part and skills development using creative methods. The review also suggests that successful priority setting processes with young people involve consideration of power dynamics, since young people's decisions are likely to be made together with family members, health professionals and academics. Discussion: Young people's engagement in decision-making about their health is best achieved through investing time in building strong relationships and ensuring young people are appropriately rewarded for their time and contribution. If young people are to be instrumental in improving their health and architects of their own futures, decision-making processes need to respect young people's autonomy and agency. Our review suggests that methods of power-sharing with young people do exist but that they have yet to be adopted by organisations and global institutions setting global health policy. [ABSTRACT FROM AUTHOR]

Background: There is a large and growing unmet need for rehabilitation - a diverse category of services that aim to improve functioning across the life course - particularly in low- and middle-income countries. Yet despite urgent calls to increase political commitment, many low- and middle-income country governments have dedicated little attention to expanding rehabilitation services. Existing policy scholarship explains how and why health issues reach the policy agenda and offers applicable evidence to advance access to physical, medical, psychosocial, and other types of rehabilitation services. Drawing from this scholarship and empirical data on rehabilitation, this paper proposes a policy framework to understand national-level prioritization of rehabilitation in low- and middle-income countries., Methods: We conducted key informant interviews with rehabilitation stakeholders in 47 countries, complemented by a purposeful review of peer-reviewed and gray literature to achieve thematic saturation. We analyzed the data abductively using a thematic synthesis methodology. Rehabilitation-specific findings were triangulated with policy theory and empirical case studies on the prioritization of other health issues to develop the framework., Results: The novel policy framework includes three components which shape the prioritization of rehabilitation on low- and middle-income countries' national government's health agendas. First, rehabilitation lacks a consistent problem definition, undermining the development of consensus-driven solutions which could advance the issue on policy agendas. Second, governance arrangements are fragmented within and across government ministries, between the government and its citizens, and across national and transnational actors engaged in rehabilitation service provision. Third, national legacies - particularly from civil conflict - and weaknesses in the existing health system influences both rehabilitation needs and implementation feasibility., Conclusions: This framework can support stakeholders in identifying the key components impeding prioritization for rehabilitation across different national contexts. This is a crucial step for ultimately better advancing the issue on national policy agendas and improving equity in access to rehabilitation services., (© 2023. The Author(s).)

Background: Health inequalities are persistent and widening with transformative policy change needed. Radically shifting policy to tackle upstream causes of inequalities is likely to require public participation to provide a mandate, evidence and to address questions of co-design, implementation and acceptability. The aim of this paper is to explore perceptions among policy actors on why and how the public should be involved in policymaking for health inequalities., Methods: In 2019-2020, we conducted exploratory, in-depth, semi-structured interviews with 21 Scottish policy actors from a range of public sector bodies and agencies and third sector organisations that work in, or across, health and non-health sectors. Data were analysed thematically and used to examine implications for the development of participatory policymaking., Results: Policy actors viewed public participation in policymaking as intrinsically valuable for democratic reasons, but the main, and more challenging, concern was with how it could affect positive policy change. Participation was seen as instrumental in two overlapping ways: as evidence to improve policies to tackle health inequalities and to achieve public acceptance for implementing more transformative policies. However, our analysis suggests a paradox: whilst policy actors place importance on the instrumental value of public participation, they simultaneously believe the public hold views about health inequalities that would prevent transformative change. Finally, despite broad agreement on the need to improve public participation in policy development, policy actors were uncertain about how to make the necessary changes due to conceptual, methodological and practical challenges., Conclusions: Policy actors believe in the importance of public participation in policy to address health inequalities for intrinsic and instrumental reasons. Yet, there is an evident tension between seeing public participation as a route to upstream policies and a belief that public views might be misinformed, individualistic, short-term or self-interested and doubts about how to make public participation meaningful. We lack good insight into what the public think about policy solutions to health inequalities. We propose that research needs to shift from describing the problem to focusing more on potential solutions and outline a potential way forward to undertake effective public participation to tackle health inequalities., (© 2023. The Author(s).)

Background: Air pollution has been identified as related to the diseases of susceptible population, but the spatial heterogeneity of its economic burden and its determinants are rarely investigated. The issue is of great policy significance, especially after the epidemic of COVID-19, when human are facing the joint crisis of health and environment, and some areas is prone to falling into poverty. Methods: The geographical detector was adopted to study the spatial distribution characteristics of the incidence of catastrophic health expenditure (ICHE) for older adults in 100 rural areas in China at the prefecture-city level. The health factors, sociological factors, policy factors and environmental factors and their interactions are identified. Results: First, most health service factors had strong explanatory power for ICHE whether it interacts with air pollution. Second, 50 single-factor high-risk areas of ICHE were found in the study, but at the same time, there were 21 areas dominated by multiple factors. Conclusion: The different contributions and synergy among the factors constitute the complex mechanism of factors and catastrophic health expenditure. Moreover, during this process, air pollution aggravates the contribution of health service factors toward ICHE. In addition, the leading factors of ICHE are different among regions. At the end, this paper also puts forward some policy suggestions from the perspective of health and environment crisis in the post-COVID-19 world: environmental protection policies should be combined with the prevention of infectious diseases; advanced health investment is the most cost-effective policy for the inverse health sequences of air pollution and infectious diseases such as coronavirus disease 2019 (COVID-19); integrating environmental protection policy into healthy development policy, different regions take targeted measures to cope with the intertwined crisis. [ABSTRACT FROM AUTHOR]

Mental health is impacted by social, economic, and environmental factors, the Social Determinants of Health (SDH). Migrants experiencing precarious living and working conditions may be more at risk of poor mental health than the majority population. This paper aims to evaluate the relationship of educational attainment and other SDH with depressive symptoms among the resident population, including Italians and migrants. This study examined the respondents to the Italian "Progressi delle Aziende Sanitarie per la Salute in Italia" (PASSI) surveillance system, 2014–18. The sample of 144.055 respondents is composed of the resident working adults aged 25–69 with Italian citizenship (n = 136.514) and foreign citizenship (n = 7.491). Findings show that among Italians high level of education appears to be a protective factor for mental health, in accordance with the international evidence (adjPR: tertiary education 0,74 p-value = 0.000). However, among immigrants high level of education is associated with the presence of depressive symptoms (adjPR: tertiary education: 1.61 p-value = 0.006), particularly for men (adjPR: tertiary education: 2.40 p-value = 0.006). The longer the length of stay in Italy for immigrants the higher the risk of depressive symptoms: adjPR for 10+ years: 2.23 p-value = 0.005. The data show that high education could represent a risk factor for mental health of immigrants. Moreover, among migrants there are some significant mental health inequities between male and female related to the duration of stay in Italy, economic activity and educational level. Considering that health is related to the nature of society as well as to access to technical solutions, multicultural societies require culturally oriented interventions for tackling health inequities. This means developing evidence-based policies in order to tackle health inequalities in the population as a whole, including culturally oriented measures in the larger framework of developing diversity sensitive services. [ABSTRACT FROM AUTHOR]

Background: China now faces an increasingly aging society which may exert economic pressure in the long run. This study illustrates the spatial pattern and evolution of population aging and economic development in China. The coupling coordination degree of population aging and economic development at the national and provincial levels are calculated and demonstrated, and the spatial patterns and characteristics are investigated. Methods: This paper presents a coupling analysis of the elderly population rate (EPR) and per capita Gross Regional Product (GRPpc) in China by using the coupling and coordination model. Further, the spatial pattern and evolution of population aging and economic development are investigated based on the standard deviational ellipse. The collected data is at the level of provincial administrative units in mainland China covering the period 2002 to 2020. Results: The results reveal the spatial difference in the coupling and coordination degree between EPR and GRPpc across provinces. The eastern coastal areas are higher than the central and western regions of China. The orientation and directions of EPR are more than GRPpc, indicating that the polarization in population aging is more severe than economic development. Significant positive correlations between coupling coordination degree and sustainable competitiveness are detected. Conclusions: Policymakers should fully consider regional differences and sustainable development in policy formulation of China. The western and northeastern provinces should be given priority in the regional sustainable development plan. At the same time, the coordination between population aging and economic development also requires to be examined especially. [ABSTRACT FROM AUTHOR]

Background: Spurred by the WHO's endorsement of universal health coverage as a goal of all health systems, many countries are undertaking health financing reforms. The nature of these reforms, and the policy processes by which they are achieved, will depend on context-specific factors, including the history of reform efforts and the political imperatives driving reforms. South Africa's pursuit of universal health coverage through a National Health Insurance is the latest in a nearly 100-year history of health system reform efforts shaped by social and political realities. Methods: We conducted an interdisciplinary, retrospective literature review to explore how these reform efforts have unfolded, and been shaped by the contextual realities of the moment. We began the review by identifying peer-reviewed literature on health system reform in South Africa, and iteratively expanded the search through author tracking, citation tracking and purposeful searches for material on particular events or processes referenced in the initial body of evidence. Data was extracted and organised chronologically into nine periods. Results: The analysis suggests that in South Africa politics; the power of the private sector; competing policy priorities and budgetary constraints; and ideas, values and ideologies have been particularly important in constraining, and sometimes spurring, health system reform efforts. Political transitions and pressures - including the introduction of apartheid in 1948, anti-apartheid opposition, the transition to democracy, and corruption and governance failures - have alternately created political imperatives for reform, and constrained reform efforts. In addition, the country's political history has given rise to dominant ideas, values and ideologies that imbue health system reform with a particular social meaning. While these ideas and values increase opposition and complicate reform efforts, they also help to expose the inequities of the current system as problematic and re-emphasise the need for reform. Conclusion: Ultimately, this analysis demonstrates the context-specific nature of health system reform processes and the influence of history on what sorts of reforms are politically feasible and socially acceptable, even in the context of a global push for universal health coverage. [ABSTRACT FROM AUTHOR]

Introduction: Reduction in health inequalities and providing universal access to health care have been identified as two important global milestones by the World Health Organization for countries to achieve by 2030. Therefore, recognizing the magnitude of oral health inequalities in India has become a pressing priority to improve access to dental care within the country. This scoping review was conducted with the aim of reviewing, collating and analysing the current knowledge base on oral health inequalities in India. Methodology: The scoping review followed Arksey and O'Malley's approach, and reporting was performed in accordance with the PRISMA-ScR guidelines. A systematic search was conducted on Scopus, PubMed, Web of Science, and EMBASE to identify literature addressing one or more dimensions of oral health inequalities in India, published in English between January 2002 and April 2022. The data were charted, and qualitative analysis was performed to derive themes, highlighting the key concepts emerging from this review. Results: In accordance with the eligibility criteria, a total of 71 articles retrieved through database search and backward citation search were included in this scoping review. The major themes ranged from individual to diverse sociodemographic factors acting as barriers to and facilitators of access to dental care. Deficiencies in human resources for oral health, along with a wide diversity in dental service provision and dental education were other major themes contributing to inequality. Subsequently, this has resulted in recommendations on restructuring the dental workforce and their development and modifications in oral health care policies and practices. The qualitative synthesis demonstrates the intertwined nature of the multiple factors that influence the goal of achieving an affordable, accessible, extensive and inclusive oral healthcare system in India. Conclusions: This comprehensive review provides a broad perspective on oral health inequalities in India, providing valuable insights for both researchers and policymakers in this area and guiding their efforts towards achieving universal oral health coverage in the Indian context. [ABSTRACT FROM AUTHOR]

Background: During the first decade of the current century, Latin American countries have shown high and consistent economic growth rates, increasing per capita GDP and reducing poverty. Social indicators improved in even the poorest and least equitable countries in the region. In terms of health care results, marked advances were made in infant mortality rates. Objective: The aim of this paper is to identify if decreasing poverty rates in Latin America and the Caribbean during the first decade of the century have had an effect on health inequality, specifically by reducing the health care equity gap and, if so, whether that trend and its effects were distributed evenly at the sub-national level. Methods: Basic statistical tools were applied to national and sub-national administrative data for eleven Latin American countries (Argentina, Belize, Bolivia, Brazil, Colombia, Dominican Republic, El Salvador, Mexico, Nicaragua, Peru, and Uruguay) to compare the evolution of a set of social determinants with a classic health care outcome, such infant mortality) during the period 1995–2012. This document proposes a set of indicators to analyze relative evolution of results and convergence to equity, and to discuss general trends in health care reforms across the region. Results: The document shows a correspondence between poverty reduction, and improvement of health care indicators at a regional level, though national differences persist. In some cases, like Brazil and Peru, the reduction in infant mortality rates is coupled with significant movements towards health equity. This trend is different in Bolivia, where the drop in poverty is not followed by better outcomes in poor departments. At the same, results are not necessarily linked to health systems organization and/or specific reforms. For instance, both Brazil and Peru pursue in applying decentralized solutions, although the incentive mechanisms are quite different: the former has a supply side structure at the public provision level while the latter has implemented mixed payment systems. Conclusion: While some of the same instruments and measures of effectiveness in health care reforms appear across the region, specific impact evaluations should be performed. To reduce the equity gap in Latin America requires not only major improvements in social determinants but also the design and implementation of sound institutional policy and more robust regulatory frameworks (institutional determinants) so that more resources yield better practices. [ABSTRACT FROM AUTHOR]

Background: Access to healthcare is restricted for newly arriving asylum seekers and refugees (ASR) in many receiving countries, which may lead to inequalities in health. In Germany, regular access and full entitlement to healthcare (equivalent to statutory health insurance, SHI) is only granted after a waiting time of 18 months. During this time of restricted entitlements, local authorities implement different access models to regulate asylum seekers' access to healthcare: the electronic health card (EHC) or the healthcare voucher (HV). This paper examines inequalities in access to healthcare by comparing healthcare utilization by ASR under the terms of different local models (i.e., regular access equivalent to SHI, EHC, and HV). Methods: We used data from three population-based, cross-sectional surveys among newly arrived ASR (N=863) and analyzed six outcome measures: specialist and general practitioner (GP) utilization, unmet needs for specialist and GP services, emergency department use and avoidable hospitalization. Using logistic regression, we calculated odds ratios (OR) and 95% confidence intervals for all outcome measures, while considering need by adjusting for socio-demographic characteristics and health-related covariates. Results: Compared to ASR with regular access, ASR under the HV model showed lower needs-adjusted odds of specialist utilization (OR=0.41 [0.24-0.66]) while ASR under the EHC model did not differ from ASR with regular access in any of the outcomes. The comparison between EHC and HV model showed higher odds for specialist utilization under the EHC model as compared to the HV model (OR=2.39 [1.03-5.52]). GP and emergency department utilization, unmet needs and avoidable hospitalization did not show significant differences in any of the fully adjusted models. Conclusion: ASR using the HV are disadvantaged in their access to healthcare compared to ASR having either an EHC or regular access. Given equal need, they use specialist services less. The identified inequalities constitute inequities in access to healthcare that could be reduced by policy change from HV to the EHC model during the initial 18 months waiting time, or by granting ASR regular healthcare access upon arrival. Potential patterns of differences in GP utilization, unmet needs, emergency department use and avoidable hospitalization between the models deserve further exploration in future studies. [ABSTRACT FROM AUTHOR]

Background: The health of India's children has improved over the past thirty years. Rates of morbidity and anthropometric failure have decreased. What remains unknown, however, is how those patterns have changed when examined by socioeconomic status. We examine changes in 11 indicators of child health by household wealth and maternal education between 1993 and 2021 to fill this critical gap in knowledge. Doing so could lead to policies that better target the most vulnerable children. Methods: We used data from five rounds of India's National Family Health Survey conducted in 1993, 1999, 2006, 2016, and 2021 for this repeated cross-sectional analysis. We studied mother-reported cases of acute respiratory illness and diarrhea, hemoglobin measurements for anemia, and height and weight measurements for anthropometric failure. We examined how the prevalence rates of each outcome changed between 1993 and 2021 by household wealth and maternal education. We repeated this analysis for urban and rural communities. Results: The socioeconomic gradient in 11 indicators of child health flattened between 1993 and 2021. This was in large part due to large reductions in the prevalence among children in the lowest socioeconomic groups. For most outcomes, the largest reductions occurred before 2016. Yet as of 2021, except for mild anemia, outcome prevalence remained the highest among children in the lowest socioeconomic groups. Furthermore, we show that increases in the prevalence of stunting and wasting between 2016 and 2021 are largely driven by increases in the severe forms of these outcomes among children in the highest socioeconomic groups. This finding underscores the importance of examining child health outcomes by severity. Conclusions: Despite substantial reductions in the socioeconomic gradient in 11 indicators of child health between 1993 and 2021, outcome prevalence remained the highest among children in the lowest socioeconomic groups in most cases. Thus, our findings emphasize the need for a continued focus on India's most vulnerable children. [ABSTRACT FROM AUTHOR]

Introduction: Neighbourhood effect on health outcomes is well established, but little is known about its effect on access to essential health services (EHS). Therefore, this study aimed to assess the contributing factors to access to EHS in slum versus non-slum settings. Methodology: The most recent data from 58 Demographic and Health Surveys (DHS) conducted between 2011 and 2018 were used, including a total of 157,000 pairs of currently married women aged 15–49 and their children aged 12–23 months. We used meta-analysis techniques to examine the inequality gaps in suboptimal access to EHS between mother-children pairs living in slums and non-slums. Blinder-Oaxaca decomposition technique was used to identify the factors contributing to the inequality gaps in each low- and middle-income country (LMIC) included. Result: The percentage of mother–child pairs living in slums ranged from 0.5% in Egypt to 63.7% in Congo. Meta-analysis of proportions for the pooled sample revealed that 31.2% [27.1, 35.5] of slum residents and 20.0% [15.3, 25.2] among non-slum residents had suboptimal access to EHS. We observed significant pro-slum inequalities in suboptimal access to EHS in 28 of the 52 LMICs with sufficient data. Of the 34 African countries included, 16 showed statistically significant pro-slum inequality in suboptimal access to EHS, with the highest in Egypt and Mali (2.64 [0.84–4.44] and 1.76 [1.65, 1.87] respectively). Findings from the decomposition analysis showed that, on average, household wealth, neighbourhood education level, access to media, and neighbourhood-level illiteracy contributed mostly to slum & non-slum inequality gaps in suboptimal access to EHS. Conclusion: The study showed evidence of inequality in access to EHS due to neighbourhood effects in 26 LMICs. This evidence suggests that increased focus on the urban poor might be a important for increasing access to EHS and achieving the universal health coverage (UHC) goals. [ABSTRACT FROM AUTHOR]

Abstract Context The COVID-19 pandemic has reignited a commitment from the health policy and health services research communities to rebuilding trust in healthcare and created a renewed appetite for measures of trust for system monitoring and evaluation. The aim of the present paper was to develop a multidimensional measure of trust in healthcare that: (1) Is responsive to the conceptual and methodological limitations of existing measures; (2) Can be used to identify systemic explanations for lower levels of trust in equity-deserving populations; (3) Can be used to design and evaluate interventions aiming to (re)build trust. Methods We conducted a 2021 review of existing measures of trust in healthcare, 72 qualitative interviews (Aug-Dec 2021; oversampling for equity-deserving populations), an expert review consensus process (Oct 2021), and factor analyses and validation testing based on two waves of survey data (Nov 2021, n = 694; Jan-Feb 2022, n = 740 respectively). Findings We present the Trust in Multidimensional Healthcare Systems Scale (TIMHSS); a 38-item correlated three-factor measure of trust in doctors, policies, and the system. Measurement of invariance tests suggest that the TIMHSS can also be reliably administered to diverse populations. Conclusions This global measure of trust in healthcare can be used to measure trust over time at a population level, or used within specific subpopulations, to inform interventions to (re)build trust. It can also be used within a clinical setting to provide a stronger evidence base for associations between trust and therapeutic outcomes.

Background: Globally, non-communicable diseases (NCDs) are increasingly the primary cause of mortality and morbidity among women. Like many developing countries, Bangladesh also faces a growing burden of NCDs. The "Multisectoral Action Plan for Prevention and Control of Non-communicable Diseases, 2018–2025" signifies Bangladesh's commitment to comprehensively combating the rising burden of NCDs. This study investigates the perceptions of those involved in developing the action plan and if/how a gender lens was incorporated into its implementation. Methods: In-depth interviews were conducted with 25 key individuals involved in a high-level committee to develop and implement Bangladesh's multisectoral action plan to address the burden of NCDs. Data were collected between July and November 2021, and thematic analysis was conducted. Results: The findings revealed that interviewees believed the multisectoral action plan adopted a population-wide approach without considering gender-specific needs. This study presents the explanations for this inattention under five themes: (1) A population-level approach to NCD prevention; (2) Understanding women's health beyond reproductive health; (3) Absence of gender-specific programs; (4) Lack of consideration of gender constraints on physical activity; and (5) Lack of collaborative efforts to address NCDs beyond the health ministry. Conclusion: In conclusion, governments in countries like Bangladesh can develop more effective strategies to reduce the disease burden of NCDs among women by recognizing and addressing the gendered nature of preventive health. This can be achieved by promoting gender-responsive research, programs, and policy initiatives that consider women's specific health concerns, ultimately leading to better health outcomes for all. [ABSTRACT FROM AUTHOR]

Background: Community health workers (CHWs) are central to Primary Health Care globally. Amidst the current flourishing of work on CHWs, there often is a lack of reference to history—even in studies of programs that have been around for decades. This study examines the 35-year trajectory of Nepal's Female Community Health Volunteers (FCHVs). Methods: We conducted a content analysis of an archive of primary and secondary research materials, grey literature and government reports collected during 1977-2019 across several regions in Nepal. Documents were coded in MAXQDA using principles of inductive coding. As questions arose from the materials, data were triangulated with published sources. Results: Looking across four decades of the program's history illuminates that issues of gender, workload, and pay—hotly debated in the CHW literature now—have been topics of discussion for observers and FCHVs alike since the inception of the program. Following experiments with predominantly male community volunteers during the 1970s, Nepal scaled up the all-female FCHV program in the late 1980s and early 1990s, in part because of programmatic goals focused on maternal and child health. FCHVs gained legitimacy as health workers in part through participation in donor-funded vertical campaigns. FCHVs received a stable yet modest regular stipend during the early years, but since it was stopped in the 1990s, incentives have been a mix of activity-based payments and in-kind support. With increasing outmigration of men from villages and growing work responsibilities for women, the opportunity cost of health volunteering increased. FCHVs started voicing their dissatisfaction with remuneration, which gave rise to labor movements starting in the 2010s. Government officials have not comprehensively responded to demands by FCHVs for decent work, instead questioning the relevance of FCHVs in a modern, medicalized Nepali health system. Conclusions: Across public health, an awareness of history is useful in understanding the present and avoiding past mistakes. These histories are often not well-archived, and risk getting lost. Lessons from the history of Nepal's FCHV program have much to offer present-day debates around CHW policies, particularly around gender, workload and payment. [ABSTRACT FROM AUTHOR]

Background: The construction of the ordered health delivery system in China aims to enhance equity and optimize the efficient use of medical resources by rationally allocating patients to different levels of medical institutions based on the severity of their condition. However, superior hospitals have been overcrowded, and primary healthcare facilities have been underutilized in recent years. China has developed a new case-based payment method called "Diagnostic Intervention Package" (DIP). The government is trying to use this economic lever to encourage medical institutions to actively assume treatment tasks consistent with their functional positioning and service capabilities. Methods: This study takes Tai'an, a DIP pilot city, as a case study and uses an interrupted time series analysis to analyze the impact of DIP reform on the case severity and service scope of medical institutions at different levels. Results: The results show that after the DIP reform, the proportion of patients receiving complicated procedures (tertiary hospitals: β3 = 0.197, P < 0.001; secondary hospitals: β3 = 0.132, P = 0.020) and the case mix index (tertiary hospitals: β3 = 0.022, P < 0.001; secondary hospitals: β3 = 0.008, P < 0.001) in tertiary and secondary hospitals increased, and the proportion of primary-DIP-groups cases decreased (tertiary hospitals: β3 = -0.290, P < 0.001; secondary hospitals: β3 = -1.200, P < 0.001), aligning with the anticipated policy objectives. However, the proportion of patients receiving complicated procedures (β3 = 0.186, P = 0.002) and the case mix index (β3 = 0.002, P < 0.001) in primary healthcare facilities increased after the reform, while the proportion of primary-DIP-groups cases (β3 = -0.515, P = 0.005) and primary-DIP-groups coverage (β3 = -2.011, P < 0.001) decreased, which will reduce the utilization efficiency of medical resources and increase inequity. Conclusion: The DIP reform did not effectively promote the construction of the ordered health delivery system. Policymakers need to adjust economic incentives and implement restraint mechanisms to regulate the behavior of medical institutions. [ABSTRACT FROM AUTHOR]

For the fields of implementation science and health equity, understanding and being responsive to local contexts is of utmost importance to better inform the development, implementation, and evaluation of healthcare and public health interventions to increase their uptake and sustainment. Contexts are multi-level and include political, historical, economic, and social factors that influence health, as well as organizational characteristics, reflecting the richness of members' views, resources, values, and needs. Poor alignment between solutions and those contextual characteristics could have an impact on inequities. The PRISM (Practical Robust Implementation and Sustainability Model) is a context-based implementation science framework that incorporates RE-AIM outcomes (Reach, Effectiveness, Adoption, Implementation, Maintenance) and offers guidance to researchers, practitioners, and their patient and community partners on how to conceptualize, assess, and address contextual domains with a focus on health equity. Drawing from systems thinking, participatory engagement, and health equity principles, this commentary expands on previous work to 1) offer a novel perspective on how to align an intervention's core functions and forms with the PRISM's contextual domains, and 2) foster an ongoing and iterative engagement process with diverse partners throughout the research and practice process using a co-creation approach. We recommend intervention-to-context alignment through iterative cycles. To that end, we present the RE-AIM Framework's 'outcomes cascade' to illustrate touch points of opportunity and gaps within and across each of the five RE-AIM outcomes to illustrate 'where things go wrong'. We present a case study to illustrate and offer recommendations for research and practice efforts to increase contextual responsiveness, and enhance alignment with context before, during, and after implementation efforts and to ensure equity is being addressed. We strive to make a conceptual contribution to advance the field of pragmatic research and implementation of evidence-based practices through the application of the contextually-based PRISM framework with a focus on health equity. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to examine the Coronavirus disease 2019(COVID-19) vaccine policies disparities and effectiveness in Germany, Denmark and Bulgaria, with a view to providing lessons for global vaccination and response to possible outbreak risks. Methods: This study analyzed big data through public information on the official websites of the Ministries of Health of the European Union, Germany, Denmark and Bulgaria and the official websites of the World Health Organization. We systematically summarized the COVID-19 vaccine policies of the three countries, and selected the following six indicators for cross-cutting vaccination comparisons: COVID-19 vaccine doses administered per 100 people, COVID-19 vaccination rate, the share of people with fully vaccinated, the share of people only partly vaccinated, cumulative confirmed COVID-19 cases per million, cumulative confirmed COVID-19 deaths per million. Meanwhile, we selected the following four indicators for measuring the effectiveness of COVID-19 vaccine policy implementation: daily cases per million, daily deaths per million, the effective reproduction rate (Rt), the moving-average case fatality rate (CFR). Results: Although these three EU countries had the same start time for vaccination, and the COVID-19 vaccine supply was coordinated by the EU, there are still differences in vaccination priorities, vaccination types, and vaccine appointment methods. Compared to Germany and Denmark, Bulgaria had the least efficient vaccination efforts and the worst vaccination coverage, with a vaccination rate of just over 30% as of June 2023, and the maximum daily deaths per million since vaccination began in the country was more than three times that of the other two countries. From the perspective of implementation effect, vaccination has a certain effect on reducing infection rate and death rate, but the spread of new mutant strains obviously aggravates the severity of the epidemic and reduces the effectiveness of the vaccine. Among them, the spread of the Omicron mutant strain had the most serious impact on the three countries, showing an obvious epidemic peak. Conclusions: Expanding vaccination coverage has played a positive role in reducing COVID-19 infection and mortality rates and stabilizing Rt. Priority vaccination strategies targeting older people and at-risk groups have been shown to be effective in reducing COVID-19 case severity and mortality in the population. However, the emergence and spread of new variant strains, and the relaxation of epidemic prevention policies, still led to multiple outbreaks peaking. In addition, vaccine hesitancy, mistrust in government and ill-prepared health systems are hampering vaccination efforts. Among the notable ones are divergent types of responses to vaccine safety issue could fuel mistrust and hesitancy around vaccination. At this stage, it is also necessary to continue to include COVID-19 vaccination in priority vaccination plans and promote booster vaccination to prevent severe illness and death. Improving the fairness of vaccine distribution and reducing the degree of vaccine hesitancy are the focus of future vaccination work. [ABSTRACT FROM AUTHOR]

Background: To establish a long-term mechanism to control the cost burden of drugs, the Chinese government organized seven rounds of price negotiations for the national reimbursement drug list (NRDL) from 2016 to the end of 2022. The study aimed to evaluate the impact of the National Health Insurance Coverage (NHIC) policy on the use of lenvatinib as the first-line treatment for advanced hepatocellular carcinoma (HCC) within a specific medical insurance region from the micro perspective of individual patient characteristics. Methods: The data of HCC patients that received lenvatinib from September 2019 to August 2022 was retrieved from the Medical and Health Big Data Center and longitudinally analyzed. Contingency table chi-square statistics and binary logistic regression analysis were used to compare the differences in the categorical variables. Interrupted time-series (ITS) regression analysis was performed to evaluate the changes in the utilization of lenvatinib over 36 months. Multiple linear regression was used to analyze the impact of receiving lenvatinib on the total hospitalization expenses of hospitalized patients with advanced HCC. Results: A total of 12,659 patients with advanced HCC were included in this study. The usage rate of lenvatinib increased from 6.19% to 15.28% over 36 months (P < 0.001). By controlling the other factors, consistent with this, the probability of patients with advanced HCC receiving lenvatinib increased by 2.72-fold after the implementation of the NHIC policy (OR = 2.720, 95% CI:2.396–3.088, P < 0.001). Older, residency in rural areas, lack of fixed income, treatment at hospitals below the tertiary level, and coverage by urban-rural residents' basic medical insurance (URRBMI) were the factors affecting the use of lenvatinib among patients with advanced HCC (P < 0.05). After the implementation of the NHIC policy, the total hospitalization expenses increased (Beta=-0.040, P < 0.001). However, compared to patients who received lenvatinib, the total hospitalization expenses were higher for those who did not receive the drug (US$5022.07 ± US$5488.70 vs. US$3701.63 ± US$4330.70, Beta = 0.062, P < 0.001). Conclusions: The NHIC policy has significantly increased the utilization of lenvatinib. In addition, we speculate that establishing multi-level medical insurance systems for economically disadvantaged patients would be beneficial in improving the effectiveness of the NHIC policy in the real world. [ABSTRACT FROM AUTHOR]

Background: The World Health Organisation (WHO) estimates a 10 million health worker shortage by 2030. Despite this shortage, some low-income African countries paradoxically struggle with health worker surpluses. Technically, these health workers are needed to meet the minimum health worker-population ratio, but insufficient job opportunities in the public and private sector leaves available health workers unemployed. This results in emigration and un- or underemployment, as few countries have policies or plans in place to absorb this excess capacity. Sierra Leone, Liberia and Guinea have taken a different approach; health authorities and/or public hospitals 'recruit' medical and nursing graduates on an unsalaried basis, promising eventual paid public employment. 50% Sierra Leone's health workforce is currently unsalaried. This scoping review examines the existing evidence on Sierra Leone's unsalaried health workers (UHWs) to establish what impact they have on the equitable delivery of care. Methods: A scoping review was conducted using Joanna Briggs Institute guidance. Medline, PubMed, Scopus, Web of Science were searched to identify relevant literature. Grey literature (reports) and Ministry of Health and Sanitation policy documents were also included. Results: 36 texts, containing UHW related data, met the inclusion criteria. The findings divide into two categories and nine sub-categories: Charging for care and medicines that should be free; Trust and mistrust; Accountability; Informal provision of care, Private practice and lack of regulation. Over-production of health workers; UHW issues within policy and strategy; Lack of personnel data undermines MoHS planning; Health sector finance. Conclusion: Sierra Leone's example demonstrates that UHWs undermine equitable access to healthcare, if they resort to employing a range of coping strategies to survive financially, which some do. Their impact is wide ranging and will undermine Sierra Leone's efforts to achieve Universal Health Coverage if unaddressed. These findings are relevant to other LICs with similar health worker surpluses. [ABSTRACT FROM AUTHOR]

Introduction: Child marriage remains a prevalent issue in low- and middle-income countries (LMIC) despite global declines. Girls are disproportionately affected, facing health risks, limited education, and restricted decision-making power. We aim to provide insights for child marriage prevalence across LMIC from 1990 to 2020, with a focus on sexual violence and early sexual intercourse for public health policy interventions. Methods: This study used World Bank datasets to assess progress in addressing child marriage in LMIC countries. Statistical analyses, including trend analysis and compound annual growth rate (CAGR), were conducted to evaluate indicators of first marriage, sexual violence, and sexual intercourse. Countries with sufficient data were categorized based on prevalence rates and trends, and detailed analysis focused on significant indicators. Results: While significant reductions were observed in the prevalence of child marriage before the age of 15 and 18 and early sexual intercourse in most countries, few countries show increasing trends, and others could not demonstrate statistical trends due to data limitations, such as scarcity of data for boys. Overall, many countries showed a decline in sexual violence and early sexual intercourse before the age of 15, but some exhibited increasing trends. For instance, Zambia and Senegal showed a decreasing trend of sexual violence, while Nigeria exhibited an increasing trend. Notably, Uganda, Cameroon, and Sierra Leone for women, and Namibia, Zambia, and Kenya for men, experienced substantial decline in early sexual intercourse. Conclusion: There is a decline in child marriage, sexual violence, and early sexual intercourse in most countries independent from the income group. Only a few countries show slight increasing trends. The improvements confirm that policies that address education, employment, and deep-rooted gender inequality at the societal level seem to be effective and help reach the SDG. However, better data are needed to enhance the understanding of the development of child marriage in these countries to improve the effectiveness of policy intervention. Therefore, we recommend that policymakers not only include existing evidence that continues progress but also increase and improve the monitoring of relevant indicators. Plain Language Summary: Child marriage remains a prevalent issue despite global declines, particularly affecting girls who suffer from health risks, lower education, and restricted decision-making power. However, little is known about boys in this context. This study aims to examine We aim to provide insights for child marriage prevalence across LMIC from 1990 to 2020, with a focus on sexual violence and early sexual intercourse for public health policy interventions. To achieve this, we assessed progress in addressing child marriage in LMIC countries using World Bank datasets. Through statistical analyses, including trend analysis and linear regression, we evaluated various indicators. Countries with sufficient data were categorized based on prevalence and trends. The results revealed significant reductions in all indicators, few countries show increasing trends, and others could not demonstrate statistical trends due to data limitations, such as scarcity of data for boys. The Central African Republic experienced an increase in child marriage prevalence. Overall, many countries showed a decline in sexual violence and intercourse before the age of 15, but some exhibited increasing trends. For instance, Zambia and Senegal showed a decreasing trend of sexual violence, while Nigeria exhibits an increasing trend. Notably, Uganda, Cameroon, and Sierra Leone experienced substantial declines in early sexual intercourse for women, and Namibia, Zambia, and Kenya for men. There is a decline in child marriage, sexual violence, and early sexual intercourse in most countries independent of the income group. Only a few countries show slight increasing trends. The improvements confirm that policies that address education, employment, and deep-rooted gender inequality at societal level seem to be effective and help reach the SDG. However, better data are needed to enhance the understanding of the development of child marriage in these countries to improve the effectiveness of policy intervention. Therefore, we recommend that policymakers not only include existing evidence that continues progress but also increase and improve the monitoring of relevant indicators. [ABSTRACT FROM AUTHOR]

Background: This study aimed to analyze coronavirus disease 2019 (COVID-19)vaccine policies and effectiveness in Korea, Japan, and Singapore, thereby providing empirical experience for vaccination and response to similar public health emergencies. Methods: The study systematically summarized the COVID-19 vaccine policies in Korea, Japan, and Singapore through public information from the Our World in Data website and the official websites of the Ministries of Health in these three countries.Total vaccinations, COVID-19 vaccination rates, rates of fully vaccinated, rates of boostervaccinated, and total confifirmed cases were selected for cross-sectional comparison of COVID-19 vaccination in these three countries. Combining the basic characteristics of these three countries, daily cases per million, daily deaths per million, and the effective reproduction rate were calculated to measure the effectiveness of COVID-19 vaccine policies implementation in each of these three countries Results: The countermeasures against the COVID-19 in Korea, Japan, and Singapore, although seemingly different on the surface, have all taken an aggressive approach. There are large similarities in the timing of the start of COVID-19 vaccination, the type of vaccine, how vaccine appointments are made, and whether vaccination are free, and all had high vaccination rates. A systematic comparison of the anti-epidemic practices in the three East Asian countries revealed that all three countries experienced more than one outbreak spike due to the spread of new mutant strains after the start of mass vaccination with COVID-19 vaccination, but that vaccination played a positive role in reducing the number of deaths and stabilizing the effective reproduction rate. Conclusions: This study comparatively analyzed the COVID-19 vaccine policies and their effects in South Korea, Japan, and Singapore, and found that there is a common set of logical combinations behind the seemingly different strategies of these three countries. Therefore, in the process of combating COVID-19, countries can learn from the successful experience of combating the epidemic and continue to strengthen the implementation of vaccination programs, as well as adjusting public perceptions to reduce the level of vaccine hesitancy, enhance the motivation for vaccination, and improve the coverage of COVID-19 vaccine based on different cultural factors, which remains the direction for future development. [ABSTRACT FROM AUTHOR]

Background: People experiencing long-term homelessness face significant difficulties accessing appropriate healthcare at the right time and place. This study explores how and why healthcare performance management and funding arrangements contribute to healthcare accessibility or the lack thereof using long-term homeless adults as an example of a population experiencing social exclusion. Methods: A realist evaluation was undertaken. Thirteen realist interviews were conducted after which data were transcribed, coded, and analysed. Results: Fourteen CMOCs were created based on analysis of the data collected. These were then consolidated into four higher-level CMOCs. They show that health systems characterised by fragmentation are designed to meet their own needs above the needs of patients, and they rely on practitioners with a special interest and specialised services to fill the gaps in the system. Key contexts identified in the study include: health system fragmentation; health service fragmentation; bio-medical, one problem at a time model; responsive specialised services; unresponsive mainstream services; national strategy; short health system funding cycles; and short-term goals. Conclusion: When health services are fragmented and complex, the needs of socially excluded populations such as those experiencing homelessness are not met. Health systems focus on their own metrics and rely on separate actors such as independent NGOs to fill gaps when certain people are not accommodated in the mainstream health system. As a result, health systems lack a comprehensive understanding of the needs of all population groups and fail to plan adequately, which maintains fragmentation. Policy makers must set policy and plan health services based on a full understanding of needs of all population groups. [ABSTRACT FROM AUTHOR]

Background: Migrants is a large population in China. To improve the health and wellbeing of migrants is a critical policy and social issue in China, and to enhance the utilization of primary health care by migrants is one of the most important approaches in promoting equity in health. However, there exists little research about the association between social integration and the utilization of primary health care. To address the research gap, this research aims at exploring the relation between social integration and the utilization of primary health care among migrants in China. Methods: Using the national data from China Migrants Dynamic Survey (CMDS) in 2017, 169,989 migrants were included in this study. Social integration was measured by social communication, acculturation and self-identity, with 8 indicators. The utilization of primary health care was measured by the receiving of health education on infectious diseases (ID) and noncommunicable diseases (NCD) as well as the first visit institution when migrants were sick. After the descriptive statistical analysis, binary logistic regression was employed to evaluate the association between social integration and the utilization of primary health care. Results: 65.99% of the migrants received health education on infectious diseases (ID), 40.11% of the migrants received health education on noncommunicable diseases (NCD) and 8.48% of the migrants chose to go to Community Health Center (CHC) seeking for health services. There was a positive effect of social organization participation, the influence of hometown customs, differences of hygiene habits between migrants and local people, integration willingness and evaluation of identity on the receiving of health education on ID and NCD, as well as a positive effect of civil activities engagement and differences of hygiene habits between migrants and local people on the utilization of CHC after getting sick. Conclusions: Social integration was associated with the utilization of primary health care among migrants in China. Generally speaking, greater social integration was associated with higher possibility of receiving health education on ID and NCD. However, the effect of social integration on the utilization of CHC was more complex among different indicators. There should be more policy interventions to improve the social integration of migrant which help them to get familiar with the health resource available, as well as improve the capacity of CHC. [ABSTRACT FROM AUTHOR]

Background: Health inequities exist within and between societies at different hierarchical levels. Despite overall improvements in health status in European Union countries, disparities persist among socially, economically, and societally disadvantaged individuals. This study aims to develop a holistic model of health determinants, examining the complex relationship between various determinants of health inequalities and their association with health condition. Methods: Health inequalities and conditions were assessed at the territorial level of Local Administrative Units (LAU1) in the Czech Republic. A dataset of 57 indicators was created, categorized into seven determinants of health and one health condition category. The necessary data were obtained from publicly available databases. Comparisons were made between 2001–2003 and 2016–2019. Various methods were employed, including composite indicator creation, correlation analysis, the Wilcoxon test, aggregate index calculation, cluster analysis, and data visualization using the LISA method. Results: The correlation matrix revealed strong relationships between health inequality categories in both periods. The most significant associations were observed between Economic status and social protection and Education in the first period. However, dependencies weakened in the later period, approaching values of approximately 0.50. The Wilcoxon test confirmed variations in determinant values over time, except for three specific determinants. Data visualization identified persistently adverse or worsening health inequalities in specific LAU1, focusing on categories such as Economic status and social protection, Education, Demographic situation, Environmental status, Individual living status, and Road safety and crime. The health condition indices showed no significant change over time, while the aggregate index of health inequalities improved with widened differences. Conclusion: Spatial inequalities in health persist in the Czech Republic, influenced by economic, social, demographic, and environmental factors, as well as local healthcare accessibility. Both inner and outer peripheries exhibit poor health outcomes, challenging the assumption that urban areas fare better. The combination of poverty and vulnerabilities exacerbates these inequalities. Despite the low rates of social exclusion and poverty, regional health inequalities persist in the long term. Effectively addressing health inequalities requires interdisciplinary collaboration and evidence-based policy interventions. Efforts should focus on creating supportive social and physical environments, strengthening the healthcare system, and fostering cooperation with non-medical disciplines. [ABSTRACT FROM AUTHOR]

Abstract Background There is a large and growing unmet need for rehabilitation – a diverse category of services that aim to improve functioning across the life course – particularly in low- and middle-income countries. Yet despite urgent calls to increase political commitment, many low- and middle-income country governments have dedicated little attention to expanding rehabilitation services. Existing policy scholarship explains how and why health issues reach the policy agenda and offers applicable evidence to advance access to physical, medical, psychosocial, and other types of rehabilitation services. Drawing from this scholarship and empirical data on rehabilitation, this paper proposes a policy framework to understand national-level prioritization of rehabilitation in low- and middle-income countries. Methods We conducted key informant interviews with rehabilitation stakeholders in 47 countries, complemented by a purposeful review of peer-reviewed and gray literature to achieve thematic saturation. We analyzed the data abductively using a thematic synthesis methodology. Rehabilitation-specific findings were triangulated with policy theory and empirical case studies on the prioritization of other health issues to develop the framework. Results The novel policy framework includes three components which shape the prioritization of rehabilitation on low- and middle-income countries’ national government’s health agendas. First, rehabilitation lacks a consistent problem definition, undermining the development of consensus-driven solutions which could advance the issue on policy agendas. Second, governance arrangements are fragmented within and across government ministries, between the government and its citizens, and across national and transnational actors engaged in rehabilitation service provision. Third, national legacies – particularly from civil conflict – and weaknesses in the existing health system influences both rehabilitation needs and implementation feasibility. Conclusions This framework can support stakeholders in identifying the key components impeding prioritization for rehabilitation across different national contexts. This is a crucial step for ultimately better advancing the issue on national policy agendas and improving equity in access to rehabilitation services.

Background: Women with breast cancer have different chances of surviving their disease, depending on where they live. Variations in survival may stem from unequal access to prompt diagnosis, treatment and care. Implementation of the right to health may help remedy such inequalities. The right to health is enshrined in international human rights law, notably Article 12 of the International Covenant on Economic, Social and Cultural Rights. A human rights-based approach to health requires a robust, just and efficient health system, with access to adequate health services and medicines on a non-discriminatory basis. However, it may prove challenging for health policymakers and cancer management specialists to implement and monitor this right in national health systems. Method: This article presents the results of a Delphi study designed to select indicators of implementation of the right to health to inform breast cancer care and management. In a systematic process, 13 experts examined an initial list of 151 indicators. Results: After two rounds, 54 indicators were selected by consensus, three were rejected, three were added, and 97 remained open for debate. For breast cancer, right-to-health features selected as worth implementing and monitoring included the formal recognition of the right to health in breast cancer strategies; a population-based screening programme, prompt diagnosis, strong referral systems and limited waiting times; the provision of palliative, survivorship and end-of-life care; the availability, accessibility, acceptability and quality (AAAQ) of breast cancer services and medicines; the provision of a system of accountability; and the collection of anonymised individual data to target patterns of discrimination. Conclusion: We propose a set of indicators as a guide for health policy experts seeking to design national cancer plans that are based on a human rights-based approach to health, and for cancer specialists aiming to implement principles of the right to health in their practice. The 54 indicators selected may be used in High-Income Countries, or member states of the OECD who also have signed the International Covenant on Economic, Social and Cultural Rights to monitor progress towards implementation of the right to health for women with breast cancer. [ABSTRACT FROM AUTHOR]

Background: Lung cancer mortality in European countries shows different epidemiological patterns according to sex and socioeconomic variables. Some countries show decreasing rates in both sexes, while others show a delayed profile, with increasing mortality in women, inconsistently influenced by socioeconomic status. Our aim was to evaluate the effect of age, period and birth cohort on lung cancer mortality inequalities in men and women in Andalusia, the southernmost region in Spain. Methods: We used the Longitudinal Database of the Andalusian Population, which collects demographic and mortality data from the 2001 census cohort of more than 7.35 million Andalusians, followed up between 2002 and 2016. Mortality rates were calculated for men and women by educational level, and small-area deprivation. Poisson models were used to assess trends in socioeconomic inequalities in men and women. Finally, age-period-cohort (APC) models were used separately for each educational level and gender. Results: There were 39,408 lung cancer deaths in men and 5,511 in women, yielding crude mortality rates of 78.1 and 11.4 × 105 person-years, respectively. In men higher mortality was found in less educated groups and inequalities increased during the study period: i.e. the rate ratio for primary studies compared to university studies increased from 1.30 (CI95:1.18–1.44) to 1.57 (CI95:1.43–1.73). For women, educational inequalities in favour of the less educated tended to decrease moderately. In APC analysis, a decreasing period effect in men and an increasing one in women were observed. Cohort effect differed significantly by educational level. In men, the lower the educational level, the earlier the peak effect was reached, with a 25-year difference between the least-educated and college-educated. Conversely, college-educated women reached the peak effect with a 12-year earlier cohort than the least-educated women. The decline of mortality followed the same pattern both in men and women, with the best-educated groups experiencing declining rates with earlier birth cohorts. Conclusions: Our study reveals that APC analysis by education helps to uncover changes in trends occurring in different socioeconomic and gender groups, which, combined with data on smoking prevalence, provide important clues for action. Despite its limitations, this approach to the study of lung cancer inequalities allows for the assessment of gaps in historical and current tobacco policies and the identification of population groups that need to be prioritised for public health interventions. [ABSTRACT FROM AUTHOR]

Background: Long waiting times for health care services are a prominent health policy issue. Waiting time guarantees may limit time to assessment and treatment. Methods: This study aims to investigate the information and support given to patients when the waiting time guarantee cannot be fulfilled from a care provider and administrative management perspective. Semi-structured interviews (N = 28) were conducted with administrative management and care providers (clinic staff and clinic line managers) in specialized clinics in the Stockholm Region, Sweden. Clinics were purposefully sampled for maximum variation in ownership (private, public), complexity of care, geographical location, volume of production, and waiting times. Thematic analysis was applied. Results: Care providers reported that patients received inconsistent information and support with regard to the waiting time guarantee and that information was not adapted to health literacy or individual patient needs. Contrary to local law, they made some patients responsible for finding a new care provider or arranging a new referral. Furthermore, financial interests affected whether patients were referred to other providers. Administrative management steered care providers' informing practices at specific time points (upon establishment of a new unit and after six months of operation). A specific regional support function, Region Stockholm's Care Guarantee Office, helped patients change care providers when long waiting times occurred. However, administrative management perceived that there was no established routine to assist care providers in informing patients. Conclusions: Care providers did not consider patients' health literacy when informing them about the waiting time guarantee. Administrative management's attempts to provide information and support to care providers are not producing the results they expect. Soft-law regulations and care contracts seem insufficient, and economic mechanisms undermine care providers' willingness to inform patients. The described actions are unable to mitigate the inequality in health care that arises from differences in care-seeking behavior. [ABSTRACT FROM AUTHOR]