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Background: This paper discusses the stages of health system resilience (HSR) and the factors underlying differences in HSR during the covid-19 pandemic, especially the vaccination challenge. We studied the relationship between vaccination strategies and macro-context backgrounds in 21 Latin American countries. Our objective was to capture the impact of those aspects in the SR and identify potential improvements for future crises and for vaccination programs in general. Methods: The study uses mixed-methods research to provide insights into how the countries' backgrounds and vaccination strategies impact the HSR. Particularly, we used explanatory sequential mixed methods, which entails a quantitative-qualitative two-phase sequence. The quantitative phase was conducted using cluster and variance analysis, in which the HSR was measured using as a proxy the covid-19 vaccination outcomes in three cut-offs of reaching 25%, 50%, and 75% of population coverage. This approach allows us to discriminate covid-19 vaccination progress by stages and contrast it to the qualitative stage, in which we performed a country-case analysis of the background conditions and the changes in vaccination strategies that occurred during the corresponding dates. Results: The paper provides a rich comparative case analysis of countries, classifying them by early, prompt, and delayed performers. The results show that differences in vaccination performance are due to flexibility in adapting strategies, cooperation, and the ability to design multilevel solutions that consider the needs of various actors in the health ecosystem. These differences vary depending on the vaccination stage, which suggests the importance of acknowledging learning, diffusion, and feedback processes at the regional level. Conclusions: We identified the importance of societal well-being as an ideal country antecedent for high and sustained levels of performance in covid-19 vaccination. Whereas in other countries where the set-up and beginning phases were rough, the value of the operational decisions and the learning on the move regarding their own and their peers' trajectories were crucial and were reflected in performance improvement. A contribution of this study is that the above-mentioned analysis was done using vaccination coverage cut-off points that allow a performance view that takes into consideration the stages of the vaccination progress and the learning process that goes with it. As well as framing this into the HSR shock cycles that allow to differentiate the stages of resilience on which countries must act. [ABSTRACT FROM AUTHOR]

Background: Approximately 15% of women in low-and middle-income countries experience common perinatal mental disorders. Yet, many women, even if diagnosed with mental health conditions, are untreated due to poor quality care, limited accessibility, limited knowledge, and stigma. This paper describes how mental health-related stigma influences pregnant women's decisions not to disclose their conditions and to seek treatment in Vietnam, all of which exacerbate inequitable access to maternal mental healthcare. Methods: A mixed-method realist study was conducted, comprising 22 in-depth interviews, four focus group discussions (total participants n = 44), and a self-administered questionnaire completed by 639 pregnant women. A parallel convergent model for mixed methods analysis was employed. Data were analyzed using the realist logic of analysis, an iterative process aimed at refining identified theories. Survey data underwent analysis using SPSS 22 and descriptive analysis. Qualitative data were analyzed using configurations of context, mechanisms, and outcomes to elucidate causal links and provide explanations for complexity. Results: Nearly half of pregnant women (43.5%) would try to hide their mental health issues and 38.3% avoid having help from a mental health professional, highlighting the substantial extent of stigma affecting health-seeking and accessing care. Four key areas highlight the role of stigma in maternal mental health: fear and stigmatizing language contribute to the concealment of mental illness, rendering it unnoticed; unconsciousness, normalization, and low literacy of maternal mental health; shame, household structure and gender roles during pregnancy; and the interplay of regulations, referral pathways, and access to mental health support services further compounds the challenges. Conclusion: Addressing mental health-related stigma could influence the decision of disclosure and health-seeking behaviors, which could in turn improve responsiveness of the local health system to the needs of pregnant women with mental health needs, by offering prompt attention, a wide range of choices, and improved communication. Potential interventions to decrease stigma and improve access to mental healthcare for pregnant women in Vietnam should target structural and organizational levels and may include improvements in screening and referrals for perinatal mental care screening, thus preventing complications. [ABSTRACT FROM AUTHOR]

Background: In Guatemala, Indigenous women have a maternal mortality ratio over twice that of non-Indigenous women. Long-standing marginalization of Indigenous groups and three decades of civil war have resulted in persistent linguistic, economic, cultural, and physical barriers to maternity care. Curamericas/Guatemala facilitated the development of three community-built, -owned, and -operated birthing centers, Casas Maternas Rurales (referred to here as Community Birthing Centers), where auxiliary nurses provided physically accessible and culturally acceptable clinical care. The objective of this paper is to assess the management of complications and the decision-making pathways of Birthing Center staff for complication management and referral. This is the sixth paper in the series of 10 articles. Birthing centers are part of the Expanded Census-based, Impact-oriented Approach, referred to as CBIO+. Methods: We undertook an explanatory, mixed-methods study on the handling of pregnancy complications at the Birthing Centers, including a chart review of pregnancy complications encountered among 1,378 women coming to a Birthing Center between 2009 and 2016 and inductively coded interviews with Birthing Center staff. Results: During the study period, 1378 women presented to a Birthing Center for delivery-related care. Of the 211 peripartum complications encountered, 42.2% were successfully resolved at a Birthing Center and 57.8% were referred to higher-level care. Only one maternal death occurred, yielding a maternal mortality ratio of 72.6 maternal deaths per 100,000 live births. The qualitative study found that staff attribute their successful management of complications to frequent, high-quality trainings, task-shifting, a network of consultative support, and a collaborative atmosphere. Conclusion: The Birthing Centers were able to resolve almost one-half of the peripartum complications and to promptly refer almost all of the others to a higher level of care, resulting in a maternal mortality ratio less than half that for all Indigenous Guatemalan women. This is the first study we are aware of that analyzes the management of obstetrical complications in such a setting. Barriers to providing high-quality maternity care, including obtaining care for complications, need to be addressed to ensure that all pregnant women in such settings have access to a level of care that is their fundamental human right. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Equity and justice in healthcare payment form an integral part of health policy and planning. In the majority of low and middle-income countries (LMICs), healthcare inequalities are further aggravated by Out of Pocket Expenditure (OOPE). This paper examines the pattern of health equity and regional disparities in healthcare spending among Indian states by applying Andersen's behavioural model of healthcare utilization. Methods: The present study uses data from the 66th quinquennial round of Consumer Expenditure Survey, of the National Sample Survey Organization (NSSO), conducted in 2009-10 by Ministry of Statistics and Programme Implementation (MoSPI), Government of India (GoI). To measure equity and regional disparities in healthcare expenditure, states have been categorized under three heads on the basis of monthly OOPE i.e., Category A (OOPE > =INR 100); Category B (OOPE between INR 50 to 99) and Category C (OOPE < INR 50). Multiple Generalised Linear Regression Model (GLRM) has been employed to explore the effect of various socio-economic covariates on the level of OOPE. Results: The gap in the ratio of average healthcare spending between the poorest and richest households was maximum in Category A states Category B (richest/poorest = 14.60), followed by (richest/poorest 11.70) and Category C (richest/poorest 11.40). Results also indicate geographical concentration of lower level healthcare spending among Indian states (e.g., Odisha, Chhattisgarh and all the north-eastern states). Results from the multivariate analysis suggest that people residing in urban areas, having higher economic status, belonging to non-Muslim communities, non-Scheduled Tribes (STs), and non-poor households spend more on healthcare than their counterparts. Conclusions: In spite of various efforts by the government to reduce the burden of healthcare spending, widespread inequalities in healthcare expenditure are prevalent. Households with high healthcare needs (SCs/STs, and the poor) are in a more disadvantaged position in terms of spending on health care. It has also been observed that spending on healthcare was comparatively lower among backward or isolated states. No doubt, the overall social security measures should be enhanced, but at the same time, looking at the regional differences, more priority should be assigned to the disadvantaged states to reduce the burden of OOPE. It is proposed that there is need to increase government spending, especially for the disadvantaged states and population, to minimise the burden of OOPE. [ABSTRACT FROM AUTHOR]

Background: Rates of exclusive breastfeeding fall below recommended levels, particularly among women in paid employment. In Mexico, more than half of women are in informal employment, meaning they lack many of the protections that may support breastfeeding. Methods: In-depth interviews with 15 key informants representing government agencies (n = 6 organizations), NGOs (n = 4), international organizations (n = 2), and academia (n = 2) in Mexico. Interviews were conducted between March and June 2023. To understand and describe barriers to breastfeeding among informally employed women in Mexico according to key informants and the current and potential policies to address these barriers, we conducted a qualitative thematic analysis. Results: Current policies to promote, protect, and support breastfeeding predominantly apply to all employed women, but respondents expressed concern that they did not provide adequate protection for women in informal employment. Additional themes concerned the need for relevant programs to be institutionalized and coordinated, discussions of breastfeeding as a right, and the legal equivalence (whether true in practice or not) of formal and informal workers. Conclusions: Women employed in Mexico's informal sector face a dearth of maternity protections. According to key informants, few policies exist to promote, protect, and support breastfeeding among employed women, in general, but the economic vulnerability and challenging working conditions of women in informal employment exacerbates their situation. The lack of access to formal labor protections, such as paid maternity leave, creates a significant barrier to breastfeeding for women in the informal sector. Recommendations include short-term policies to fill gaps in social protection for informally employed women, as well as longer-term solutions such as the development of universal social protection programs and supporting formalization. [ABSTRACT FROM AUTHOR]

Background: The concept of collaborative approaches involves community residents in joint decision-making processes to maintain or enhance their material and social conditions. During COVID-19, public services saw the benefits of actively collaborating with communities and involving residents in decision-making processes. As communities have resources and assets, they are well-placed to contribute to developing local health and wellbeing initiatives. An interdisciplinary and nationally funded three-phase research programme, "Mobilising community assets to tackle health inequalities", was established with the objective of utilising local, cultural, and natural assets to support health and wellbeing. The current study aimed to synthesise evidence collected by research teams awarded funding in phase one of the programme, comprising academic and non-academic, health and social care, voluntary and community partners. Methods: Ten online focus groups were conducted with research teams from across the UK exploring the successes and challenges of partnership working to tackle health inequalities using collaborative approaches to community-based research. Eight focus group questions were split between partnership working and health inequalities. Results: Thematic and content analysis produced 185 subthemes from which 12 themes were identified. Major themes representing an above average number of coded responses were research evidence; funding; relationships with partners; health inequalities and deprivation; community involvement; and health service and integrated care systems. Minor themes were link workers and social prescribing; training and support; place-based factors; longevity of programmes; setting up and scaling up programmes; and mental health. Conclusions: Successes included employing practice-based and arts-based methods, being part of a research project for those not normally involved in research, sharing funding democratically, building on established relationships, and the vital role that local assets play in involving communities. Challenges involved a lack of sustainable financial support, the short-term nature of funding, inconsistencies in reaching the poorest people, obtaining the right sort of research evidence, making sufficient research progress, building relationships with already over-burdened health care staff, and redressing the balance of power in favour of communities. Despite the challenges, participants were mainly optimistic that collective approaches and meaningful co-production would create opportunities for future research partnerships with communities. [ABSTRACT FROM AUTHOR]

Introduction: Women's access to legal and safe abortion is a vital means to reduce unsafe abortion, which in turn is known to reduce maternal morbidity and mortality. In 2005, Ethiopia enacted a relatively permissive abortion legislation. However, there is evidence that access to abortion care services may be challenging and controversial even if progressive abortion laws are in place. This article examines women's access to abortion services from the perspective of healthcare workers in a rural setting in Ethiopia. Drawing on Lipsky's theory of street-level bureaucrats, the article discusses healthcare workers' discretion and the substantial authority they hold as gatekeepers to safe abortion services. Methods: The study draws upon a qualitative, interpretative methodological approach, with in-depth semi-structured interviews with healthcare workers as the key method of data generation. The data was analyzed and interpreted thematically. Healthcare workers' perspectives were examined with reference to the national abortion legislation and guidelines. Results: The findings reveal that healthcare workers make decisions on behalf of the women who seek abortion, and they involve parents and partners in abortion-related decision-making processes. Moreover, they assess the social context of the pregnancy such as the marital and economic statuses of the abortion-seeking women in ways that restrict women's access to legally-endorsed abortion services. Conclusions: Healthcare workers' practices in this rural area were found to challenge the basic provisions laid out in Ethiopia's abortion legislation. Their negative discretion of the legislation contributes to the substantial barriers Ethiopian abortion-seeking women face in gaining access to legal abortion services, despite the presence of a progressive legal framework and guidelines. [ABSTRACT FROM AUTHOR]

Background: Since 2020, China has implemented an innovative payment method called Diagnosis-Intervention Packet (DIP) in 71 cities nationwide. This study aims to assess the impact of DIP on medical expenditure, efficiency, and quality for inpatients covered by the Urban Employee Basic Medical Insurance (UEBMI) and Urban and Rural Residents Basic Medical Insurance (URRBMI). It seeks to explore whether there are differences in these effects among inpatients of the two insurance types, thereby further understanding its implications for health equity. Materials and methods: We conducted interrupted time series analyses on outcome variables reflecting medical expenditure, efficiency, and quality for both UEBMI and URRBMI inpatients, based on a dataset comprising 621,125 inpatient reimbursement records spanning from June 2019 to June 2023 in City A. This dataset included 110,656 records for UEBMI inpatients and 510,469 records for URRBMI inpatients. Results: After the reform, the average expenditure per hospital admission for UEBMI inpatients did not significantly differ but continued to follow an upward pattern. In contrast, for URRBMI inpatients, the trend shifted from increasing before the reform to decreasing after the reform, with a decline of 0.5%. The average length of stay for UEBMI showed no significant changes after the reform, whereas there was a noticeable downward trend in the average length of stay for URRBMI. The out-of-pocket expenditure (OOP) per hospital admission, 7-day all-cause readmission rate and 30-day all-cause readmission rate for both UEBMI and URRBMI inpatients showed a downward trend after the reform. Conclusion: The DIP reform implemented different upper limits on budgets based on the type of medical insurance, leading to varying post-treatment prices for UEBMI and URRBMI inpatients within the same DIP group. After the DIP reform, the average expenditure per hospital admission and the average length of stay remained unchanged for UEBMI inpatients, whereas URRBMI inpatients experienced a decrease. This trend has sparked concerns about hospitals potentially favoring UEBMI inpatients. Encouragingly, both UEBMI and URRBMI inpatients have seen positive outcomes in terms of alleviating patient financial burdens and enhancing the quality of care. [ABSTRACT FROM AUTHOR]

Background: Young people (aged 10 to 24 years) in sub-Saharan Africa bear a huge and disproportionate burden of poor sexual and reproductive health (SRH) outcomes due to inequalities and discrimination in accessing sexual and reproductive health services (SRHS). This study assessed the experiences and perceptions of discrimination among young people seeking SRH services in Primary Health Centers (PHCs) using an intersectionality lens. Methods: A cross-sectional mixed-methods study was undertaken in six local government areas (LGAs) in Ebonyi State, southeast Nigeria. The LGAs comprise both urban and rural locations. The study population for the quantitative survey consisted of 1025 randomly selected young boys and girls aged 15–24 years. Eleven focus group discussions (FGDs) were conducted with the young people. Descriptive and inferential analyses were performed for quantitative data, while thematic analysis was performed for the qualitative data, using NVivo. Results: A total of 16.68% participants in the survey reported that young girls/women were treated badly/unfairly compared to young boys/men when seeking SRH services in PHCs; 15.22% reported that young clients get treated badly/unfairly from adults; and 12.49% reported that young clients with poor economic status were treated unfairly. Respondents also reported that young clients with disability (12.12%), and those who are poorly educated or uneducated (10.63%) are treated badly by healthcare providers when they access SRH services. Young people in urban areas were about 7 times more likely to believe that girls/young women are treated badly than boys/young men when seeking SRH services in PHCs compared to those who live in rural areas (p < 0.001). Among the young girls/women, residing in urban areas, being poor and in school increased the likelihood of getting treated badly/unfairly when receiving SRH services by 4 times (p < 0.001). The qualitative results revealed that health workers were generally harsh to young people seeking SRH services and the level of harshness or unfriendliness of the health workers varied depending on the young person's social identity. Conclusion: There are varieties of intersecting factors that contribute to the discrimination of young clients in PHCs. This underscores the urgent need to prioritize intersectional perspectives in the design and implementation of interventions that will improve access and use of SRH services by young people. [ABSTRACT FROM AUTHOR]

Background: Despite the resources and personnel mobilized in Latin America and the Caribbean to reduce the maternal mortality ratio (MMR, maternal deaths per 100 000 live births) in women aged 10–54 years by 75% between 2000 and 2015, the region failed to meet the Millenium Development Goals (MDGs) due to persistent barriers to access quality reproductive, maternal, and neonatal health services. Methods: Using 1990–2019 data from the Global Burden of Disease project, we carried out a two-stepwise analysis to (a) identify the differences in the MMR temporal patterns and (b) assess its relationship with selected indicators: government health expenditure (GHE), the GHE as percentage of gross domestic product (GDP), the availability of human resources for health (HRH), the coverage of effective interventions to reduce maternal mortality, and the level of economic development of each country. Findings: In the descriptive analysis, we observed a heterogeneous overall reduction of MMR in the region between 1990 and 2019 and heterogeneous overall increases in the GHE, GHE/GDP, and HRH availability. The correlation analysis showed a close, negative, and dependent association of the economic development level between the MMR and GHE per capita, the percentage of GHE to GDP, the availability of HRH, and the coverage of SBA. We observed the lowest MMRs when GHE as a percentage of GDP was close to 3% or about US$400 GHE per capita, HRH availability of 6 doctors, nurses, and midwives per 1,000 inhabitants, and skilled birth attendance levels above 90%. Conclusions: Within the framework of the Sustainable Development Goals (SDGs) agenda, health policies aimed at the effective reduction of maternal mortality should consider allocating more resources as a necessary but not sufficient condition to achieve the goals and should prioritize the implementation of new forms of care with a gender and rights approach, as well as strengthening actions focused on vulnerable groups. [ABSTRACT FROM AUTHOR]

Background: Family caregivers are vital for long-term care for persons with serious health-related suffering in Kerala. Long-term caregiving and ageing may become burdensome and detrimental to patients and caregivers. We compared the caregiver burden and quality-of-life of ageing caregivers with younger caregivers. We also explored the palliative care nurses' perceptions of the family caregivers' issues. Methods: We did a mixed method study focusing on two groups: (i) three in-depth interviews and a cross-sectional survey among 221 caregivers of palliative care patients in five randomly selected panchayats (most peripheral tier of three-tier local self-government system in India concerned with governance of a village or small town) of Kollam district, Kerala, as part of development and validation of the Achutha Menon Centre Caregiver Burden Inventory; (ii) five in-depth interviews with purposively selected primary palliative care nurses as part of a study on local governments and palliative care. We used a structured interview schedule to collect cross-sectional data on sociodemographic and caregiving-related characteristics, caregiver burden, and health-related quality of life using the EuroQol EQ5D5L and interview guidelines on caregiver issues tailored based on participant type for qualitative interviews. Results: Older caregivers comprised 28.1% of the sample and had significantly poorer health and quality-of-life attributes. More senior caregivers experiencing caregiver burden had the lowest mean scores of 0.877 (Standard deviation (SD 0.066, 95% confidence intervals (CI) 0.854–0.899) followed by younger caregivers with high burden (0.926, SD 0.090, 95% CI 0.907–0.945), older caregivers with low burden (0.935, SD 0.058, 95% CI 0.912–0.958) and younger caregivers with low burden (0.980, SD 0.041, 95% CI 0.970–0.990). Caregivers faced physical, psychological, social, and financial issues, leading to a caregiver burden. The relationships between the palliative care nurses and family caregivers were complex, and nurses perceived caregiver burden, but there were no specific interventions to address this. Conclusion: In our study from Kollam, Kerala, three out of ten caregivers of palliative care patients were 60 years of age or older. They had significantly lower health-related quality of life, particularly if they perceived caregiver burden. Despite being recognized by palliative care nurses, caregiver issues were not systematically addressed. Further research and suitable interventions must be developed to target such problems in the palliative care programme in Kerala. [ABSTRACT FROM AUTHOR]

Background: This paper uses the concepts of organisational culture and organisational trust to explore the Implementation of equity-oriented policies -- the Uniform Patient Fee Schedule (UPFS) and Patients' Rights Charter (PRC) - in two South African district hospitals. It contributes to the small literatures on organisational culture and trust in low- and middle-income country health systems, and broader work on health systems' people-centeredness and "software". Methods: The research entailed semi-structured interviews (Hospital A n = 115, Hospital B n = 80) with provincial, regional, district and hospital managers, as well as clinical and non-clinical hospital staff, hospital board members, and patients; observations of policy implementation, organisational functioning, staff interactions and patient-provider interactions; and structured surveys operationalising the Competing Values Framework for measuring organisational culture (Hospital A n = 155, Hospital B n = 77) and Organisational Trust Inventory (Hospital A n = 185, Hospital B n = 92) for assessing staff-manager trust. Results: Regarding the UPFS, the hospitals' implementation approaches were similar in that both primarily understood it to be about revenue generation, granting fee exemptions was not a major focus, and considerable activity, facility management support, and provincial support was mobilised behind the UPFS. The hospitals' PRC paths diverged quite significantly, as Hospital A was more explicit in communicating and implementing the PRC, while the policy also enjoyed stronger managerial support in Hospital A than Hospital B. Beneath these experiences lie differences in how people's values, decisions and relationships influence health system functioning and in how the nature of policies, culture, trust and power dynamics can combine to create enabling or disabling micro-level implementation environments. Conclusions: Achieving equity in practice requires managers to take account of "unseen" but important factors such as organisational culture and trust, which are key aspects of the organisational context that can profoundly influence policies. In addition to implementation "hardware" such as putting in place necessary staff and resources, it emphasises "software" implementation tasks such as relationship management and the negotiation of values, where equity-oriented policies might be interpreted as challenging health workers' status and values, and paying careful attention to how policies are practically framed and translated into practice, to ensure key equity aspects are not neglected. [ABSTRACT FROM AUTHOR]

Background: Geographical distribution of healthcare resources is an important dimension of healthcare access. Little work has been published on healthcare resource allocation patterns in China, despite public equity concerns. Methods: Using national data from 2043 counties, this paper investigates the geographic distribution of hospital beds at the county level in China. We performed Gini coefficient analysis to measure inequalities and ordinary least squares regression with fixed provincial effects and additional spatial specifications to assess key determinants. Results: We found that provinces in west China have the least equitable resource distribution. We also found that the distribution of hospital beds is highly spatially clustered. Finally, we found that both county-level savings and government revenue show a strong positive relationship with county level hospital bed density. Conclusions: We argue for more widespread use of disaggregated, geographical data in health policy-making in China to support the rational allocation of healthcare resources, thus promoting efficiency and equity. [ABSTRACT FROM AUTHOR]

Background: Health is recognized as a fundamental right in Brazil's constitution. In the absence of a clearly defined benefit packages of healthcare services that are financed under the Unified Health System (Sistema Único de Saúde, SUS), courts have become important in adjudicating coverage decisions. Empirical assessments of equity and the right to health tend to focus on simple measures of access. However, these empirical perspectives belie the significant inequalities and rights violations that arise in the case of more complex health needs such as cancer. To shed light on these issues, this paper focuses on the care pathways for breast and cervical cancer and explores access and quality issues that arise at different points along the care pathway with implications for the realization of the right to health in Brazil. Method: A mixed method approach is used. The analysis is primarily based on a quantitative analysis of national representative administrative data principally from the cervical and breast cancer information systems and the hospital cancer registry. To gain more insights into the organization of cancer care, qualitative data was collected from the state of Bahia, through document analysis, direct observation, roundtable discussions with health workers (HWs), and structured interviews with health care administrators. Results: The paper reveals that the volume of completed screening exams is well below the estimated need, and a tendency toward lower breast cancer screening rates in poorer states and for women in the lowest income brackets. Only 26% of breast cancer cases and 29% of cervical cancer cases are diagnosed at an early stage (stage 0 or I), thereby reducing the survival prospects of patients. Waiting times between confirmed diagnosis and treatment are long, despite new legislation that guarantees a maximum of 60 days. The waiting times are significantly longer for patients that follow the recommended patient pathways, and who are diagnosed outside the hospital. Conclusion: The study reveals that there are large variations between states and patients, where the poorest states and patients fare worse on key indicators. More broadly, the paper shows the importance of collecting data both on patient characteristics and health system performance and carry out detailed health system analysis for exposing, empirically, rights violations and for identifying how they can be addressed. [ABSTRACT FROM AUTHOR]

Background: Since its emergence, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has caused severe health, social and economic challenges. Mental healthcare has been significantly affected globally, and even worse in developing countries. An emerging economy like Ghana in West Africa was not spared its disruptive effects. This study aimed to elucidate the impact of the coronavirus disease 2019, the COVID-19 pandemic (caused by SARS-CoV-2), on Ghana's mental healthcare system. Methods: This is a mixed-method study using an emergent sequential exploratory design. A total of 15 front-line healthcare professionals were recruited from the three psychiatric hospitals, including the mental health department of a new teaching hospital in Ghana. Purposive sampling techniques and a semi-structured interview approach were used for recruitment and data collection. Quantitative data from hospital registries were collected and analysed to triangulate qualitative findings. Results: Fifteen mental health workers were enrolled in the study. The mean age of participants was (34.47 ± 4.07) years, average work experience of (6.23 ± 3.64) years and the majority as males (60%). This study found an average decline of 23% in hospital attendance and a 35% decline in admissions in all four facilities compared to the previous year, 2019. The lived experiences shared by mental healthcare providers were grouped under 3 main themes: Adjustments to workplace regulations, accessibility to mental healthcare, and psychological wellbeing of mental healthcare workers. The fear of contracting SARS-CoV-2 among healthcare workers, medication shortages, and logistical challenges were also reported to affect Mental Health services during the pandemic. Conclusion: This study highlights the challenges in mental healthcare during the COVID-19 pandemic in Ghana. The experiences encountered present an opportunity to gain insights into future pandemic preparedness and establish a framework for optimal mental healthcare delivery in Ghana. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic is impacting individuals and society's physical and mental health. Despite the lack of any definite and effective therapeutic regimen, public health measures such as quarantine and isolation have been instituted to contain this pandemic. However, these mitigating measures have also raised issues regarding isolated patients' mental and psychological well-being. Several stakeholders were engaged in this approach, including the university, the local health office, the tertiary hospital, and the local communities. This intervention addresses concerns regarding the health status of isolated individuals due to COVID-19 infection, making the program available to anyone who agrees to participate. This was done through telehealth services delivered via phone calls and SMS. The university provided technical support and telehealth manpower through medical students. The local health unit manages the isolation facilities, while the referral hospital offers specialty care for isolated patients through teleconsultation. Finally, the local community is the one that reintegrates discharged patients into their communities. Three hundred forty-four (344) participants were provided seven sessions on telehealth education and tracking of their COVID-19 prescribed practices and mental health. The mean age of the patients was 37 years; half were females, and 15% had comorbidities. Regarding their mental health status, the level of depression dropped from 6% to 1% (p<0.0001), the level of anxiety dropped from 12% to 2% (p<0.0001), and the level of stress dropped from 3% to 0% (p<0.0001) from the first day of admission to 2 weeks after discharge. Moreover, a general trend of statistically significant increase in various practices was noted: wearing face masks, physical distancing, disinfecting frequently held objects, hand hygiene, and self-monitoring for COVID-19 symptoms. Those with progressing symptoms of COVID-19 were referred immediately to the referral hospital. There were also no reports of complications of co-morbidities during their stay in the isolation facilities or social isolation upon community reintegration. The study concludes that telehealth services have the potential to address many challenges in providing continuous healthcare services to isolated patients until they are reintegrated into their community. Furthermore, a whole-of-society approach is necessary to provide holistic care to patients affected by the pandemic. [ABSTRACT FROM AUTHOR]

Background: Social health inequalities are still of great public health importance in modern societies. The COVID-19 pandemic may have affected social inequalities in people's health due to containment measures. As these measures particularly affected children, they might have been particularly vulnerable to increased social inequalities. The aim of the study was to describe health inequalities during the pandemic based on language delay (LD) in children in order to inform public health interventions for a population at risk of long-term health and education inequalities. Methods: Data of 5–7 year old children from three consecutive school entry surveys in the German federal state of Brandenburg were used, including data compulsorily collected before the pandemic (2018/2019: n = 19,299), at the beginning of the pandemic (2019/2020: n = 19,916) and during the pandemic (2020/2021: n = 19,698). Bivariate and multivariate binary regression analyses [OR, 95% CI] cross-sectionally examined the relationship between the prevalence of LD [yes/no] and social inequalities, operationalized by family socioeconomic position [SEP low/middle/high], migration background [native-German language/non-native German language] and length of kindergarten attendance [< 4 years/ ≥ 4 years]. Factors contributing to inequality in LD were examined by socioeconomic stratification. Results: Cross-sectionally, LD prevalence has decreased overall (2018/2019: 21.1%, 2019/2020: 19.2%, 2020/2021: 18.8%), and among children from both high SEP and native German-speaking families. As LD prevalence increased among children from families with low SEP and remained stable among non-native German speakers, social inequalities in LD prevalence increased slightly during the pandemic i) by low SEP (2018/2019: OR = 4.41, 3.93–4.94; 2020/2021: OR = 5.12, 4.54–5.77) and ii) by non-German native language (2018/2019: OR = 2.22, 1.86–2.66; 2020/2021: OR = 2.54, 2.19–2.95). During the pandemic, both migration background and kindergarten attendance determined LD prevalence in the high and middle SEP strata. However, the measured factors did not contribute to LD prevalence in children from families with low SEP. Conclusion: Social inequalities in LD increased due to opposing trends in prevalence comparing low and high SEP families. To promote health equity across the life course, early childhood should be of interest for tailored public health actions (e.g. through targeted interventions for kindergarten groups). Further analytical studies should investigate determinants (e.g., parental investment). [ABSTRACT FROM AUTHOR]

Background: Vaccine hesitancy exists on a continuum ranging between complete adherence and complete refusal due to doubts or concerns within a heterogeneous group of individuals. Despite widespread acknowledgement of the contextual factors influencing attitudes and beliefs shaping COVID-19 vaccine hesitancy, qualitative research with equity-deserving groups, accounting for unique lived experiences, remains a gap in the literature. We aim to identify and begin to understand and document the unique contextual factors shaping hesitancy by equity-deserving groups as it relates to relationships with government and health authorities. Methods: Participants were recruited and interviewed between Aug-Dec 2021. Semi-structured interviews using a convergent interviewing technique were conducted with individuals from the general population, as well as individuals who identify as First Nations, Métis, or Inuit, members of the LGBT2SQ + community, low-income Canadians, Black Canadians, and newcomers. Interviews were audio recorded and transcribed by a team of researchers. Memos were written following interviews and used to complement the thematic analysis of the interview data. Themes are presented in the results section. Results: The rationale for hesitancy among equity-deserving groups is consistent with literature documenting hesitancy in the general population. Contextual factors surrounding equity-deserving groups' attitudes and beliefs, however, are unique and relate to a history of oppression, discrimination, and genocide. We identified factors unique to subgroups; for example, religious or fatalistic beliefs among participant who identify as FNMI, fear associated with lack of testing and speed of vaccines' production among participants who identify as FNMI, Black, and LGBT2SQ + , distrust of the healthcare system for LGBT2SQ + and Black Canadians, and distrust of the government and opposition to vaccine mandates for participating who identify as LGBT2SQ + , low-income, FNMI, or Black Canadian. Newcomers stood out as very trusting of the government and accepting of COVID-19 vaccination. Conclusions: While our data on vaccine hesitancy largely mirror concerns reported in the vast body of literature citing rationale for COVID-19 hesitancy in high-income countries, the contextual factors identified in our work point to the need for wider systemic change. Our results may be used to support efforts, beyond tailored promotion campaigns, to support the confident acceptance of vaccines for COVID-19 and the acceptance of novel vaccines as future infectious diseases emerge. [ABSTRACT FROM AUTHOR]

Introduction The health of Indigenous Australians is worse than that of other Australians. Most of the determinants of health are preventable and the poor health outcomes are inequitable. The Australian Government recently pledged to close that health gap. One possible way is to improve the priority setting process to ensure transparency and the use of evidence such as epidemiology, equity and economic evaluation. The purpose of this research was to elicit the perceptions of Indigenous and non-Indigenous decision-makers on several issues related to priority setting in Indigenous-specific health care services. Specifically, we aimed to: 1. identify the criteria used to set priorities in Indigenous-specific health care services; 2. determine the level of uptake of economic evaluation evidence by decision-makers and how to improve its uptake; and 3. identify how the priority setting process can be improved from the perspective of decisionmakers. Methods We used a paper survey instrument, adapted from Mitton and colleagues' work, and a faceto- face interview approach to elicit decision-makers' perceptions in Indigenous-specific health care in Victoria, Australia. We used mixed methods to analyse data from the survey. Responses were summarised using descriptive statistics and content analysis. Results were reported as numbers and percentages. Results The size of the health burden; sustainability and acceptability of interventions; historical trends/patterns; and efficiency are key criteria for making choices in Indigenous health in Victoria. There is a need for an explicit priority setting approach, which is systematic, and is able to use available data/evidence, such as economic evaluation evidence. The involvement of Indigenous Australians in the process would potentially make the process acceptable. Conclusions An economic approach to priority setting is a potentially acceptable and useful tool for Aboriginal Community Controlled Health Services (ACCHS). It has the ability to use evidence and ensure due process at the same time. The use of evidence can ensure that health outcomes for Indigenous peoples can be maximised - hence, increase the potential for 'closing the gap' between Indigenous and other Australians. [ABSTRACT FROM AUTHOR]

Introduction Access to quality maternal health services mainly depends on existing policies, regulations, skilled and knowledge, perceptions, and economic power and motivation of service givers and target users. Critics question policy recommending involvement of traditional birth attendants (TBAs) in emergency obstetric care (EmoC) services in developing countries. Objectives This paper reports about knowledge and practices of TBAs on EmoC in Kigoma Rural District, Tanzania and discusses policy implications on involving TBAs in maternal health services. Methods 157 TBAs were identified from several villages in 2005, interviewed and observed on their knowledge and practice in relation to EmoC. Quantitative and qualitative techniques were used for data collection and analysis depending on the nature of the information required. Findings Among a total of 157 TBAs approached, 57.3% were aged 50+ years while 50% had no formal education. Assisting mothers to deliver without taking their full pregnancy history was confessed by 11% of all respondents. Having been attending pregnant women with complications was experienced by 71.2% of all respondents. Only 58% expressed adequate knowledge on symptoms and signs of pregnancy complications. Lack of knowledge on possible risk of HIV infections while assisting childbirth without taking protective gears was claimed by 5.7% of the respondents. Sharing the same pair of gloves between successful deliveries was reported to be a common practice by 21.1% of the respondents. Use of unsafe delivery materials including local herbs and pieces of cloth for protecting themselves against HIV infections was reported as being commonly practiced among 27.6% of the respondents. Vaginal examination before and during delivery was done by only a few respondents. Conclusion TBAs in Tanzania are still consulted by people living in underserved areas. Unfortunately, TBAs' inadequate knowledge on EmOC issues seems to have contributed to the rising concerns about their competence to deliver the recommended maternal services. Thus, the authorities seeming to recognize and promote TBAs should provide support to TBAs in relation to necessary training and giving them essential working facilities, routine supportive supervision and rewarding those seeming to comply with the standard guidelines for delivering EmoC services. [ABSTRACT FROM AUTHOR]

Introduction: Research on the intimate partnerships of female sex workers (FSWs) tends to focus on the risks associated with these relationships. This paper takes as its starting point that the situation of FSWs is better understood by including knowledge of the benefits of their intimate partnerships. Specifically, we employ the conceptual framework provided by emergent research examining intimacy as a complex fusion of affective and instrumental dimensions among sex workers. This perspective allows us to frame information about FSWs' intimate partnerships within a behaviour-structural approach that is helpful for identifying how intimate partnerships can be a source of both benefit as well as increased risk to FSWs. Methods: Our results are based on a mixed-methods study carried out in the summer of 2011 in Kibera, Kenya. We conducted face-to-face interviews (n=30) with a non-probability sample of FSWs stratified by age who self-identified as Human Immune Virus positive (HIV+). We asked about participants' involvement in current and past intimate partnerships, and whether these relationships had a positive or negative impact on their health and well?being. Results: Participants currently in intimate partnerships had fewer clients and thus lower incomes than those without intimate partnerships. Participants presently with partners were also more likely to receive some financial support from partners, to report lower intimate partner violence, and to narrate higher partner emotional support and greater assistance with medications. These participants were also more likely to have disclosed their sex work and HIV+ statuses to their partners. Intimate partnerships, on the other hand, showed increased risk of economic vulnerability and emotional dependence for FSWs. This became especially problematic for those participants in fragile relationships. Despite these variations, none of the differences between the two groups were statistically significant. Conclusions: Intimacy and transactional relations are bound up with one another and intersect with the structural realities and vulnerabilities; this is the case for sex workers in well-resourced and resourced-constrained countries alike. Rather than treating intimate partnerships as distinct from transactional relationships, FSWs' relationships should be viewed on a continuum of risk and support. [ABSTRACT FROM AUTHOR]

Introduction: The prevalence of undernutrition, which is closely associated with socioeconomic and sanitation conditions, is often higher among indigenous than non-indigenous children in many countries. In Brazil, in spite of overall reductions in the prevalence of undernutrition in recent decades, the nutritional situation of indigenous children remains worrying. The First National Survey of Indigenous People's Health and Nutrition in Brazil, conducted in 2008-2009, was the first study to evaluate a nationwide representative sample of indigenous peoples. This paper presents findings from this study on the nutritional status of indigenous children < 5 years of age in Brazil. Methods: A multi-stage sampling was employed to obtain a representative sample of the indigenous population residing in villages in four Brazilian regions (North, Northeast, Central-West, and Southeast/South). Initially, a stratified probabilistic sampling was carried out for indigenous villages located in these regions. Households in sampled villages were selected by census or systematic sampling depending on the village population. The survey evaluated the health and nutritional status of children < 5 years, in addition to interviewing mothers or caretakers. Results: Height and weight measurements were taken of 6,050 and 6,075 children, respectively. Prevalence rates of stunting, underweight, and wasting were 25.7%, 5.9%, and 1.3%, respectively. Even after controlling for confounding, the prevalence rates of underweight and stunting were higher among children in the North region, in low socioeconomic status households, in households with poorer sanitary conditions, with anemic mothers, with low birthweight, and who were hospitalized during the prior 6 months. A protective effect of breastfeeding for underweight was observed for children under 12 months. Conclusions: The elevated rate of stunting observed in indigenous children approximates that of non-indigenous Brazilians four decades ago, before major health reforms greatly reduced its occurrence nationwide. Prevalence rates of undernutrition were associated with socioeconomic variables including income, household goods, schooling, and access to sanitation services, among other variables. Providing important baseline data for future comparison, these findings further suggest the relevance of social, economic, and environmental factors at different scales (local, regional, and national) for the nutritional status of indigenous peoples. [ABSTRACT FROM AUTHOR]

Introduction: The residents of many Australian rural and remote communities do not have the essential infrastructure and services required to support healthy living conditions and community members choosing healthy lifestyle options. Improving these social determinants of health is seen to offer real opportunities to improve health among such disadvantaged populations. In this paper, we describe the development and trialling of a tool to measure, monitor and evaluate key social determinants of health at community level. Methods: The tool was developed and piloted through a multi-phase and iterative process that involved a series of consultations with community members and key stakeholders and trialling the tool in remote Indigenous communities in the Northern Territory of Australia. Results: The indicators were found to be robust, and by testing the tool on a number of different levels, face validity was confirmed. The scoring system was well understood and easily followed by Indigenous and non-Indigenous study participants. A facilitated small group process was found to reduce bias in scoring of indicators. Conclusion: The Healthy Community Assessment Tool offers a useful vehicle and process to help those involved in planning, service provision and more generally promoting improvements in community social determinants of health. The tool offers many potential uses and benefits for those seeking to address inequities in the social determinants of health in remote communities. Maximum benefits in using the tool are likely to be gained with cross-sector involvement and when assessments are part of a continuous quality improvement program. [ABSTRACT FROM AUTHOR]

Introduction: Indigenous Australians experience more aggressive cancers and higher cancer mortality rates than other Australians. Cancer patients undergoing treatment are likely to access health services (e.g. social worker, cancer helpline, pain management services). To date Indigenous cancer patients' use of these services is limited. This paper describes the use of health services by Indigenous cancer patients. Methods: Indigenous cancer patients receiving treatment were recruited at four major Queensland public hospitals (Royal Brisbane Women's Hospital, Princess Alexandra, Cairns Base Hospital and Townsville Hospital). Participants were invited to complete a structured questionnaire during a face-to-face interview which sought information about their use of community and allied health services. Results: Of the 157 patients interviewed most were women (54.1%), of Aboriginal descent (73.9%), lived outer regional areas (40.1%) and had a mean age of 52.2 years. The most frequent cancer types were breast cancer (22.3%), blood related (14.0%), lung (12.1%) and gastroenterological (10.8%). More than half of the participants reported using at least one of the 'Indigenous Health Worker/Services' (76.4%), 'Allied Health Workers/Services' (72.6%) and 'Information Sources' (70.7%). Younger participants 19-39 years were more likely to use information sources (81.0%) than older participants who more commonly used community services (48.8%). The cancer patients used a median of three health services groups while receiving cancer treatment. Conclusions: Indigenous cancer patients used a range of health services whilst receiving treatment. Indigenous Health Workers/Services and Allied Health Workers/Services were the most commonly used services. However, there is a need for further systematic investigation into the health service utilization by Indigenous cancer patients. [ABSTRACT FROM AUTHOR]

Background: Racial/ethnic inequities along the HIV care continuum persist in the United States despite substantial federal investment. Numerous studies highlight individual and social-level impediments in HIV, but fewer foreground systemic barriers. The present qualitative study sought to uncover and describe systemic barriers to the HIV care continuum from the perspectives of African American/Black and Latino persons living with HIV (PLWH) with unsuppressed HIV viral load, including how barriers operated and their effects. Methods: Participants were African American/Black and Latino PLWH with unsuppressed HIV viral load (N = 41). They were purposively sampled for maximum variability on key indices from a larger study. They engaged in semi-structured in-depth interviews that were audio-recorded and professionally transcribed. Data were analyzed using directed content analysis. Results: Participants were 49 years old, on average (SD = 9), 76% were assigned male sex at birth, 83% were African American/Black and 17% Latino, 34% were sexual minorities (i.e., non-heterosexual), and 22% were transgender/gender-nonbinary. All had indications of chronic poverty. Participants had been diagnosed with HIV 19 years prior to the study, on average (SD = 9). The majority (76%) had taken HIV medication in the six weeks before enrollment, but at levels insufficient to reach HIV viral suppression. Findings underscored a primary theme describing chronic poverty as a fundamental cause of poor engagement. Related subthemes were: negative aspects of congregate versus private housing settings (e.g., triggering substance use and social isolation); generally positive experiences with health care providers, although structural and cultural competency appeared insufficient and managing health care systems was difficult; pharmacies illegally purchased HIV medication from PLWH; and COVID-19 exacerbated barriers. Participants described mitigation strategies and evidenced resilience. Conclusions: To reduce racial/ethnic inequities and end the HIV epidemic, it is necessary to understand African American/Black and Latino PLWH's perspectives on the systemic impediments they experience throughout the HIV care continuum. This study uncovers and describes a number of salient barriers and how they operate, including unexpected findings regarding drug diversion and negative aspects of congregate housing. There is growing awareness that systemic racism is a core determinant of systemic barriers to HIV care continuum engagement. Findings are interpreted in this context. [ABSTRACT FROM AUTHOR]

Belize has the highest national prevalence of type 2 diabetes (T2D) of Central and South America, and fifth direst in the world. T2D is the leading cause of death in Belize, a country facing burdens of increasing prevalence with few resources. Since March of 2020, the COVID-19 pandemic has exacerbated the difficulties of those living with T2D in Belize. To address T2D issues in Belize, our interdisciplinary research team explored the barriers to care and self-management for adult patients with T2D in Belize prior to and during the COVID-19 pandemic. Research relationships between Canadian (ARH) and Belizean (LE) authors have been ongoing since 2016. Together we used a qualitative Constructivist Grounded Theory design generating knowledge through 35 semi-structured patient interviews, 25 key informant discussions, and participant observation with field notes between February 2020 to September 2021. We used Dedoose analysis software for a systematized thematic coding process, as well as iterative verification activities. Findings revealed several barriers to care and self-management, including: 1) the tiered health and social care system with major gaps in coverage; 2) the unfulfilled demand for accurate health information and innovative dissemination methods; and 3) the compounding of loss of community supports, physical exercise, and health services due to COVID-19 restrictions. In the post-pandemic period, it is necessary to invest in physical, nutritional, economic, and psychosocial health through organized activities adaptable to changeable public health restrictions. Recommendations for activities include sending patients informational and motivational text messages, providing recipes with accessibly sourced T2D foods, televising educational workshops, making online tools more accessible, and mobilising community and peer support networks. [ABSTRACT FROM AUTHOR]

Background: In low-and middle-income countries, migrants are confronted with health needs which affect the promotion of their well-being and healthy lives. However, not much is known about the health needs of migrant female head porters (Kayayei) in Ghana. This study assesses the health needs of migrant female head porters in the Greater Kumasi Metropolitan Area (GKMA) and Greater Accra Metropolitan Area (GAMA). Methods: The study adopted a convergent mixed methods design where both qualitative and quantitative data were used. A representative sample size of 470 migrant female head porters was used for the study. Results: The study revealed that ante-natal care, post-natal care, treatment of malaria, treatment of diarrhoea diseases, mental health, sexual health, and cervical cancer were health needs of migrant female head porters. The findings showed that participants from the GAMA significantly have greater cervical cancer needs (71.6% vrs 67.1%, p = 0.001) compared to those from the GKMA. Kayeyei from the GKMA significantly have greater mental health needs than those from the GAMA (84.6% vrs 79.2%, p = 0.031). Also, Kayeyei from the GKMA significantly have higher attendance of post-natal care compared to those from the GAMA (99.4% vrs 96.2%, p = 0.013). Conclusion: The findings underscore differential health needs across geographical localities. Based on the findings of the study, specific health needs such as ante-natal care and post-natal care should be included in any health programmes and policies that aim at addressing health needs of migrant female head porters in the two metropolitan areas of Ghana. [ABSTRACT FROM AUTHOR]

Background: Research on the needs of people with disability is scarce, which promotes inadequate programs. Community Based Inclusive Development interventions aim to promote rights but demand a high level of community participation. This study aimed to identify prioritized needs as well as lessons learned for successful project implementation in different Latin American communities. Methods: This study was based on a Community Based Inclusive Development project conducted from 2018 to 2021 led by a Columbian team in Columbia, Brazil and Bolivia. Within a sequential mixed methods design, we first retrospectively analyzed the project baseline data and then conducted Focus Group Discussions, together with ratings of community participation levels. Quantitative descriptive and between group analysis of the baseline survey were used to identify and compare sociodemographic characteristics and prioritized needs of participating communities. We conducted qualitative thematic analysis on Focus Group Discussions, using deductive main categories for triangulation: 1) prioritized needs and 2) lessons learned, with subcategories project impact, facilitators, barriers and community participation. Community participation was assessed via spidergrams. Key findings were compared with triangulation protocols. Results: A total of 348 people with disability from 6 urban settings participated in the baseline survey, with a mean age of 37.6 years (SD 23.8). Out of these, 18 participated within the four Focus Group Discussions. Less than half of the survey participants were able to read and calculate (42.0%) and reported knowledge on health care routes (46.0%). Unemployment (87.9%) and inadequate housing (57.8%) were other prioritized needs across countries. Focus Group Discussions revealed needs within health, education, livelihood, social and empowerment domains. Participants highlighted positive project impact in work inclusion, self-esteem and ability for self-advocacy. Facilitators included individual leadership, community networks and previous reputation of participating organizations. Barriers against successful project implementation were inadequate contextualization, lack of resources and on-site support, mostly due to the COVID-19 pandemic. The overall level of community participation was high (mean score 4.0/5) with lower levels in Brazil (3.8/5) and Bolivia (3.2/5). Conclusion: People with disability still face significant needs. Community Based Inclusive Development can initiate positive changes, but adequate contextualization and on-site support should be assured. [ABSTRACT FROM AUTHOR]

Background: Public assistance recipients have diverse and complex needs for health and social support in addition to financial support. Segmentation, which means dividing the population into subgroups (segments) with similar sociodemographic characteristics, is a useful approach for allocating support resources to the targeted segments. Clustering is a commonly used statistical method of segmentation in a data-driven marketing approach. This explanatory sequential mixed methods study applied a clustering technique, aiming to identify segments among older public assistance recipients quantitatively, and assess the meaningfulness of the identified segments in consultation and support activities for older recipients qualitatively. Methods: We identified the segments of older recipients in two municipalities using probabilistic latent semantic analysis, a machine learning-based soft clustering method. Semi-structured interviews were subsequently conducted with caseworkers to ask whether the identified segments could be meaningful for them in practice and to provide a reason if they could not think of any older recipients from the segment. Results: A total of 3,165 older people on public assistance were included in the analysis. Five distinct segments of older recipients were identified for each sex from 1,483 men and 1,682 women. The qualitative findings suggested most of identified segments reflected older recipients in practice, especially two of them: female Cluster 1 (facility residents aged over 85 years with disability/psychiatric disorder), and female Cluster 2 (workers). Some caseworkers, however, did not recall older recipients in practice when working with certain segments. Conclusions: A clustering technique can be useful to identify the meaningful segments among older recipients and can potentially discover previously unrecognized segments that may not emerge through regular consultation practices followed by caseworkers. Future research should investigate whether tailored support interventions for these identified segments are effective. [ABSTRACT FROM AUTHOR]

Background: People experiencing homelessness (PEH) are known to be at higher risk of adverse health outcomes and premature mortality when compared to the housed population and often face significant barriers when attempting to access health services. This study aimed to better understand the specific health care needs of PEH and the barriers and facilitators associated with their timely and equitable access to health services in the European context. Methods: We conducted an exploratory cross-national qualitative study involving people with lived experience of homelessness and health and social care professionals in Austria, Greece, Spain, and the UK. A total of 69 semi-structured interviews comprising 15 social care professionals, 19 health care professionals, and 35 PEH were completed, transcribed, and analysed thematically. Results: Findings were organised into three overarching themes relating to the research question: (a) Health care needs of PEH, (b) Barriers to health care access, and (c) Facilitators to health care access. Overall, the general health of PEH was depicted as extremely poor, and mainstream health services were portrayed as ill-equipped to respond to the needs of this population. Adopting tailored approaches to care, especially involving trusted professionals in the delivery of care, was identified as a key strategy for overcoming existing barriers. Conclusions: The results of this study indicate there to be a high degree of consistency in the health care needs of PEH and the barriers and facilitators associated with their access to health care across the various European settings. Homelessness in itself is recognized to represent an essential social determinant of health, with PEH at risk of unequal access to health services. Changes are thus required to facilitate PEH's access to mainstream primary care. This can also be further complemented by investment in 'in-reach' services and other tailored and person-centred forms of health care. Trial registration: This study was registered retrospectively on June 6, 2022, in the registry of ClinicalTrials.gov under the number NCT05406687. [ABSTRACT FROM AUTHOR]

Background: Refugee women exhibit some of the highest rates of chronic pain yet the diversity and challenges of health care systems across countries pose numerous challenges for refugee women trying to access quality health care. Objective: We sought to explore the experiences of Assyrian refugee women seeking care for chronic pain. Methods: Semi-structured interviews (face-to-face and virtual) were undertaken with 10 Assyrian women of refugee background living in Melbourne, Australia. Audio recordings and field notes of interviews were collected and themes were identified using a phenomenological approach. Women were required to be conversant in English or Arabic and willing to use a translator if necessary. Results: We identified five major themes of women's experiences accessing care for chronic pain: (1) the story of pain; (2) the experience of help seeking in Australia and home country; (3) factors shaping the ability to access appropriate care; (4) support seeking systems; and (5) influence of culture and gender roles. Conclusion: Exploring refugee women's experience of seeking care for chronic pain reinforces the need to explore hard to reach population's perspectives in research and helps to understand how vectors of disadvantage may intersect. For successful integration into health care systems of host countries, particularly for complex conditions such as chronic pain, there is a need to work with women community members to develop programs that are culturally aligned to enhance access pathways to care. [ABSTRACT FROM AUTHOR]

Background: The persistence of racial/ethnic inequities in rates of engagement along the HIV care continuum signals the need for novel approaches. We developed six behavioral intervention components for use in an optimization trial, grounded in a model that integrates critical race theory, harm reduction, and self-determination theory, designed to address various barriers that African American/Black and Latino persons living with HIV (PLWH) experience to the HIV care continuum. The components were: health education, motivational interviewing sessions, pre-adherence skill building, peer mentorship, focused support groups, and navigation. The present qualitative exploratory study describes participants' perspectives on the components' acceptability, feasibility, and impact. Methods: Participants were African American/Black and Latino PLWH poorly engaged in HIV care and with non-suppressed HIV viral load in New York City. From a larger trial, we randomly selected 46 participants for in-depth semi-structured interviews. Interviews were audio-recorded and transcribed verbatim, and data were analyzed using directed content analysis. Quantitative data on sociodemographic and background characteristics and components' acceptability and feasibility were also collected. Results: On average, participants were 49 years old and had lived with HIV for 19 years. Most were cisgender-male and African American/Black. Participants reported a constellation of serious social and structural challenges to HIV management including chronic poverty, unstable housing, and stigma. Across components, a non-judgmental and pressure-free approach and attention to structural and cultural factors were seen as vital to high levels of engagement, but lacking in most medical/social service settings. Prominent aspects of individual components included establishing trust (health education); developing intrinsic motivation, goals, and self-reflection (motivational interviewing sessions); learning/practicing adherence strategies and habits (pre-adherence skill building); reducing social isolation via peer role models (peer mentorship); reflecting on salient goals and common challenges with peers without stigma (focused support groups); and circumventing structural barriers to HIV management with support (navigation). Components were found acceptable and feasible. Findings suggested ways components could be improved. Conclusions: The present study advances research on interventions for African American/Black and Latino PLWH, who experience complex barriers to engagement along the HIV care continuum. Future study of the components is warranted to address racial/ethnic health inequities in HIV. [ABSTRACT FROM AUTHOR]

Background: Migrants are overrepresented among people living with HIV in Sweden as they often face conditions that increased their risk and vulnerability for HIV/STI infections prior, during or after migration. Yet, there is limited research on their experiences and perceptions of living with HIV in the Swedish context. This study aims to explore migrants' experiences of living with HIV in Sweden. Methods: This is a qualitative study based on in-depth interviews with 13 migrants from 11 countries living with HIV in Sweden. Interviews were analysed with thematic analysis using an intersectional perspective to explore the interactions of multiple social identities such as ethnicity, socio-economic status, gender, age, and sexual orientation that shape an individual's or group's experiences. Results: The analysis resulted in a main theme: 'Prioritizing social integration-HIV ends up in second place', which is based on four subthemes: 'Better opportunities in the new country than what the home country could offer', 'Better conditions for LGBTQI people than in the home country', 'Navigating a new system: linguistic and bureaucratic challenges' and 'Feeling like a second-class resident: racism, xenophobia and multiple discrimination'. The results suggest that migrants living with HIV in Sweden experience social integration as a greater challenge than HIV infection. Although the new country offers opportunities for better living conditions, many participants described being challenged in their daily life by linguistic and structural barriers in their encounters with public services. They are facing multiple discrimination simultaneously as migrants due to their multiple and intersecting identities (e.g. being non-white, foreigners/foreign-born and non-Swedish speakers), which is compounded by HIV status and thus limit their opportunities in the new country and too often result in an existence of exclusion. Conclusion: The study shows that most of the challenges that migrants living with HIV face are related to their status as migrants rather than HIV status, which is often not known by the public or authorities. These challenges are similar, but still differ depending on social position, previous experiences, time since arrival and since diagnosis. This emphasizes the importance of both intersectional, intersectoral and multisectoral approaches to address reported issues. [ABSTRACT FROM AUTHOR]

Background: Gender equality, zero hunger and healthy lives and well-being for all, are three of the Sustainable Development Goals (SDGs) that underpin Fiji's National Development Plan. Work towards each of these goals contributes to the reduction of non-communicable diseases (NCDs). There are gender differences in NCD burden in Fiji. It is, however, unclear whether a gender lens could be more effectively included in nutrition and health-related policies. Methods: This study consisted of three components: (i) a policy content analysis of gender inclusion in nutrition and health-related policies (n = 11); (ii) policy analysis using the WHO Gender Analysis tool to identify opportunities for strengthening future policy; and (iii) informant interviews (n = 18), to understand perceptions of the prospects for gender considerations in future policies. Results: Gender equality was a goal in seven policies (64%); however, most focused on women of reproductive age. One of the policies was ranked as gender responsive. Main themes from key informant interviews were: 1) a needs-based approach for the focus on specific population groups in policies; 2) gender-related roles and responsibilities around nutrition and health; 3) what is considered "equitable" when it comes to gender, nutrition, and health; 4) current considerations of gender in policies and ideas for further gender inclusion; and 5) barriers and enablers to the inclusion of gender considerations in policies. Informants acknowledged gender differences in the burden of nutrition-related NCDs, yet most did not identify a need for stronger inclusion of gender considerations within policies. Conclusions: There is considerable scope for greater inclusion of gender in nutrition and health-related policies in Fiji. This could be done by: 1) framing gender considerations in ways that are actionable and inclusive of a range of gender identities; 2) undertaking advocacy through actor networks to highlight the need for gender-responsive nutrition and health-related policies for key stakeholder groups; 3) ensuring that data collected to monitor policy implementation is disaggregated by sex and genders; and 4) promoting equitable participation in nutrition related issues in communities and governance processes. Action on these four areas are likely critical enablers to more gender equitable NCD reduction in Fiji. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic has helped shine the spotlight on the role of women's leadership in tackling the world's health and health system challenges. The proportion of women occupying senior leadership positions in the health sector is less compared to males, even as they constitute a vast majority of the work force. The South Indian state of Kerala is an exception to this trend, a phenomenon that we sought to understand and contextualise. We undertook a study to understand the personal and professional journeys of some women leaders in the Kerala health sector to determine the antecedents of their leadership positions, the challenges that came their way in leadership, and strategies adopted to overcome these challenges. We also investigated into how these experiences shaped their styles and approaches to leadership. Methods: We conducted a qualitative study involving semi-structured in-depth interviews with women leaders. Sixteen women leaders were identified from public records and through peer nomination and interviewed in their language of preference following written informed consent procedures. Interviews focused on participants' professional and personal trajectories, work-life balance, style of leadership, challenges, enablers, lessons learned in their path, and their vision for the health system. The interviews conducted in Malayalam were transliterated into English and thematically analysed using Atlas.Ti8 software by three researchers. Results: Our study participants were aged 40 to around 80 years, from 8 out of 14 districts of the state. Women leaders in Kerala's health sector faced challenges through the life-course: during their early school education, in professional service as well as in their roles as leaders. There were myriad experiences – including gender stereotyping and discrimination at the intersection of gender and other social identities. Women developed manifold ways of overcoming them and evolve unique – and again myriad—leadership styles. Conclusions: Women leaders in Kerala have faced shared challenges through their life-course to climb up the ranks of leadership; each leader has adopted unique ways of overcoming them and developed similarly unique leadership styles. At each life stage there were bargains with patriarchy – involving family members (often as allies), against formal and informal institutional rules, managers, peers and subordinates., which in turn suggests a feminist consciousness on the part of Kerala women leaders as well as the society in which they are seeking to lead. [ABSTRACT FROM AUTHOR]

Background: Disentangling the impacts of sex and gender in understanding male and female differences is increasingly recognised as an important aspect for advancing research and addressing knowledge gaps in the field of work-health. However, achieving this goal in secondary data analyses where direct measures of gender have not been collected is challenging. This study outlines the development of a gender index, focused on gender roles and institutionalised gender, using secondary survey data from the Canadian Labour Force survey. Using this index we then examined the distribution of gender index scores among men and women, and changes in gender roles among male and female labour force participants between 1997 and 2014. Methods: We created our Labour Force Gender Index (LFGI) using information in four areas: responsibility for caring for children; occupation segregation; hours of work; and level of education. LFGI scores ranged from 0 to 10, with higher scores indicating more feminine gender roles. We examined correlations between each component in our measure and our total LFGI score. Using multivariable linear regression we examined change in LFGI score for male and female labour force participants between 1997 and 2014. Results: Although women had higher LFGI scores, indicating greater feminine gender roles, men and women were represented across the range of LFGI scores in both 1997 and 2014. Correlations indicated no redundancy between measures used to calculate LFGI scores. Between 1997 and 2014 LFGI scores increased marginally for men and decreased marginally for women. However, LFGI scores among women were still more than 1.5 points higher on average than for men in 2014. Conclusions: We have described and applied a method to create a measure of gender roles using survey data, where no direct measure of gender (masculinity/femininity) was available. This measure showed good variation among both men and women, and was responsive to change over time. The article concludes by outlining an approach to use this measure to examine the relative contribution of gender and sex on differences in health status (or other outcomes) between men and women. [ABSTRACT FROM AUTHOR]

Background: Multisectoral approaches to health are collaborations between stakeholders across multiple sectors, usually formed to address issues that affect health but go beyond the purview of one particular sector. The significance of multisectoral partnerships to attain health equity has been widely acknowledged. However, the extent which equity can be attained depends upon the perceptions of various stakeholders. We examine how multisectoral partnerships promoting healthy eating and active living conceptualized and employed an equity lens in their work. Method: This study is part of a larger pan-Canadian mixed-method research and knowledge sharing program entitled MUSE (Multisectoral Urban Systems for health and Equity in Canadian cities). Data collected from both quantitative and qualitative sources for two sites of the MUSE project-Saskatoon and Toronto were analyzed. In the qualitative part, 30 semi-structured key informant interviews were conducted with key stakeholders from six different multisectoral partnerships based in Saskatoon and Toronto. Data were analyzed in an inductive way. In the quantitative part, a survey with 37 representatives of stakeholder organizations was carried out. Simple descriptive statistics (means and percentages) were used to observe the distribution of data and to complement the qualitative analysis. Results: Equity was not a central component in program design although participants addressing equity, did so by discussing accessibility. How much consideration was given to equity varied as a function of the type of partnership. Most participants emphasized geographical accessibility but a few mentioned financial accessibility. Collaborative leadership style facilitated a participatory decision-making process, and thereby upholding equity in the partnership decision-making process. Communication, networking, and negotiation skills were found to be core competencies of a leader that contributed in upholding equity in partnership dynamics. The study also showed some challenges to embed equity in partnership works, such as the lack of comprehensive understanding of population health and its equity tenet. Conclusions: Findings indicate that multisectoral partnerships aimed at promoting healthy eating and physical activity experience several challenges to attain equity within the partnership as well as in the partnership-based works aimed at reducing health equity in populations. Factors identified can support decision makers commit to and work to attaining equity within their partnerships as well as in the partnership-based work in the community and beyond. [ABSTRACT FROM AUTHOR]

Background: Municipalities are important actors in the implementation of policies to tackle health inequalities, which requires political will, the availability of financial support, and technical and human resources. With the aim of aligning with local government political priorities, in 2017 the Barcelona Public Health Agency (Agència de Salut Pública de Barcelona, henceforth ASPB), which is responsible for the public health functions of the city, launched a strategy to improve the approach to tackling health inequalities in all its services. The objectives of this study were to show how social health inequalities were addressed in the ASPB from 2017 to 19 and to describe which actions were proposed after a participatory process aiming to create a plan to systematically incorporate health inequalities in ASPB actions. Methods: The ASPB has 304 workers, 8 directors and 20 services or departments. Participatory methodologies were carried out: 1) semi-structured interviews with department heads (N = 12, 60%); 2) world cafe workshops open to a group of workers (N = 63, 37%); 3) a Quick and Colorful voting session open to a group of workers (N = 108, 63%); and 4) Hanlon matrix with 19 actions to be prioritized (N = 12 services, 60%). Results: Semi-structured interviews and world cafe workshops provided 40 potential actions. After a step by step process of participatory prioritization, seven lines of action emerged: 1) to make progress in collaborative networking; 2) to promote policy evaluation; 3) to increase the ability of the ASPB to evaluate policies to reduce health inequalities; 4) to incorporate the axes of inequalities in all ASPB products; 5) to improve information on vulnerable groups; 6) to incorporate the gender perspective; and 7) to participate in an internal training plan to address health inequalities. Conclusions: The participation of ASPB public health professionals and staff allowed the organization to design a shared plan of actions to address health inequalities. This experience could be useful for other municipalities whose political agendas include tackling inequalities in health. [ABSTRACT FROM AUTHOR]

Alcohol is the leading cause of healthy years lost. There is significant variation in alcohol consumption patterns and harms in Australia, with those residing in the Northern Territory (NT), particularly First Nations Australians, experiencing higher alcohol-attributable harms than other Australians. Community leadership in the planning and implementation of health, including alcohol, policy is important to health outcomes for First Nations Australians. Self-determination, a cornerstone of the structural and social determinants of health, is necessary in the development of alcohol-related policy. However, there is a paucity of published literature regarding Indigenous Peoples self-determination in alcohol policy development. This study aims to identify the extent to which First Nations Australians experience self-determination in relation to current alcohol policy in Alice Springs/Mbantua (Northern Territory, Australia). Semi-structured qualitative yarns with First Nations Australian community members (n = 21) were undertaken. A framework of elements needed for self-determination in health and alcohol policy were applied to interview transcripts to assess the degree of self-determination in current alcohol policy in Alice Springs/Mbantua. Of the 36 elements, 33% were not mentioned in the interviews at all, 20% were mentioned as being present, and 75% were absent. This analysis identified issues of policy implementation, need for First Nations Australian leadership, and representation. Alcohol policy for First Nations Australians in the NT is nuanced and complicated. A conscious approach is needed to recognise and implement the right to self-determination, which must be led and defined by First Nations Australians. First Nations Australians' experiences of current alcohol policy in Central Australia: evidence of self-determination? [ABSTRACT FROM AUTHOR]

Background: The existing body of research mostly discusses inequality in physical activity (PA) based on the difference in the level of moderate-to-vigorous physical activity (MVPA). Evidence is lacking on the quantified inequality measures (e.g., how big the inequality is, and the distribution) in order to identify the most vulnerable groups of a population. This study measured PA inequality among Thai adults by using three parameters to construct an inequality index: (1) Proportion of the population with sufficient MVPA; (2) Cumulative minutes of MVPA; and (3) The Gini coefficient. Methods: This study employed three rounds of data from Thailand's Surveillance on Physical Activity (SPA) 2019–2021. In each round, over 6,000 individuals age 18–64 years were selected as nationally-representative samples, and were included in the analysis. PA inequality was constructed by using three parameters, with a combination of the three as the final measure, to identify the sub-groups of the Thai adults who are most vulnerable: groups with the least MVPA, highest insufficiency, and highest inequality index (Gini). Results: Covid-19 containment measures have widened the gap in PA inequality, as shown by a declining proportion of the population meeting the recommended guidelines, from 74.3% in 2019 to 56.7% in 2020 and 65.5% in 2021. PA inequality existed in all sub-populations. However, by combining three parameters, the most vulnerable groups during the Covid-19 epidemic were identified as follows: (1) Those with no income; (2) The unemployed; (3) Those who have no access to PA facilities; (4) Older adults aged 60 + years; and (5) Those earning < 3,500 baht per month. Further, residents of Bangkok, young adults aged 18–24, individuals who attained primary level education or less, those who had no exposure to a PA awareness campaign and those who have a debilitating chronic disease also had elevated risk of PA insufficiency. Conclusion: A concerning level of PA inequality existed in all sub-populations. The use of combined indicators in measuring PA inequality should aid in determining the most vulnerable groups of the population with a refined procedure. This method can be applied in many settings since the baseline data used to measure inequality (i.e., percent sufficient and cumulative minutes of MVPA) are widely available. [ABSTRACT FROM AUTHOR]

Background: Rates of participation in HIV care, medication uptake, and viral suppression are improving among persons living with HIV (PLWH) in the United States. Yet, disparities among African American/Black and Latino PLWH are persistent, signaling the need for new conceptual approaches. To address gaps in services and research (e.g., insufficient attention to structural/systemic factors, inadequate harm reduction services and autonomy support) and improve behavioral interventions, we integrated critical race theory, harm reduction, and self-determination theory into a new conceptual model, then used the model to develop a set of six intervention components which were tested in a larger study. The present qualitative study explores participants' perspectives on the study's acceptability, feasibility, and impact, and the conceptual model's contribution to these experiences. Methods: Participants in the larger study were African American/Black and Latino PLWH poorly engaged in HIV care and with non-suppressed HIV viral load in New York City (N = 512). We randomly selected N = 46 for in-depth semi-structured interviews on their experiences with and perspectives on the study. Interviews were audio-recorded and professionally transcribed verbatim, and data were analyzed using directed qualitative content analysis. Results: On average, participants were 49 years old (SD = 9) and had lived with HIV for 19 years (SD = 7). Most were male (78%) and African American/Black (76%). All had taken HIV medication previously. Challenging life contexts were the norm, including poverty, poor quality/unstable housing, trauma histories exacerbated by current trauma, health comorbidities, and substance use. Participants found the study highly acceptable. We organized results into four themes focused on participants' experiences of: 1) being understood as a whole person and in their structural/systemic context; 2) trustworthiness and trust; 3) opportunities for self-reflection; and 4) support of personal autonomy. The salience of nonjudgment was prominent in each theme. Themes reflected grounding in the conceptual model. Participants reported these characteristics were lacking in HIV care settings. Conclusions: The new conceptual model emphasizes the salience of systemic/structural and social factors that drive health behavior and the resultant interventions foster trust, self-reflection, engagement, and behavior change. The model has potential to enhance intervention acceptability, feasibility, and effectiveness with African American/Black and Latino PLWH. [ABSTRACT FROM AUTHOR]

Background: Social exclusion is a complex concept that is recognised as a key determinant of health. Many measurement tools developed looked at people from single excluded groups in isolation. We know from experience and literature that exclusion is often intersectional and multi-layered. Therefore, the aim of this research was to develop a social exclusion measurement tool for use in healthcare settings with individuals from any excluded group that would include questions to investigate socioeconomic elements and subjective experiences in their lives. Methods: Inductive and deductive methods were used to develop the tool. Early drafts were tested with experts (both academic and experts by experience) and modified in line with feedback received. The tool was then piloted with people in the community, and this allowed us to assess the internal consistency and validity of the tool. Exploratory factor analysis was carried out as part of this evaluation. Results: The measurement tool was initially evaluated by 17 academic and 'real world' experts. It was then piloted with seven experts by experience, two gatekeepers and two participants who were presumed not to be excluded, resulting in the development of the final tool. This was then tested with 276 participants (127 presumed excluded, 149 presumed not excluded). The socioeconomic characteristics of these participants were documented, and exploratory factor analysis was carried out on data relating to subjective items. A four-factor structure emerged comprising 22 items. Internal consistency of the factors was high, and their ability to discriminate between the two groups was notable. Conclusions: A tool for measuring the social exclusion of individuals has been developed by engaging with people from a variety of excluded groups. Socioeconomic indicators were combined with subjective items. The input of experts by experience, academics and others was sought to enhance the tool. The tool was applied to two distinct samples, showing obvious differences both in the socioeconomic items, and the items included in the factor analysis. The potential use of this tool could have positive implications for people who are excluded. [ABSTRACT FROM AUTHOR]

Background: Human trafficking is a serious global challenge associated with a complex array of health inequities for individuals, families, and communities. Consequently, in addition to a conventional criminal justice approach, anti-trafficking scholars have increasingly called for a public health approach to address this global challenge. Such calls have emphasized that a comprehensive, robust, and social justice-informed public health strategy for anti-trafficking must include services to facilitate survivors' HT exit and recovery, and to prevent their re-victimization. Fortunately, many community-based organizations and non-governmental organizations worldwide have heeded these calls and developed anti-trafficking programs for survivors. Unfortunately, despite the growing numbers of organizations providing anti-trafficking services, research concerning these programs' effectiveness remains nascent overall, and even more scant when filtered through an equity focus. Methods: To advance the field by developing guidance concerning how best to evaluate anti-human trafficking programs, an ongoing research project aims to conduct a mixed methods evaluability assessment of a prominent anti-trafficking program using a social justice framework. Guided by well-established evaluability assessment frameworks, the study activities include four sequential steps: (a) focusing the assessment, (b) developing the program theory and logic, (c) gathering feedback, and (d) applying the assessment findings. Activities will include qualitative interviews and focus groups, observations, and quantitative analysis of program data among others. Human subjects and ethical review for the evaluability assessment has been granted by the Office of Human Subjects Research at The University of North Carolina at Chapel Hill. Discussion: Once completed, evaluability assessment results will provide evidence and products that have the potential to guide both evaluation research and service provision not only for the specific organization under study, but also for other anti-human trafficking programs worldwide. Findings will be developed into a variety of dissemination products tailored for both practice professionals and researchers. In the interim, this protocol manuscript offers research strategies and recommendations that can help inform the development of other studies in the developing field of anti-trafficking program evaluation research. [ABSTRACT FROM AUTHOR]

Background: Socioeconomic status (SES) is an important determinant of health, and SES data is an important confounder to control for in epidemiology and health services research. Individual level SES measures are cumbersome to collect and susceptible to biases, while area level SES measures may have insufficient granularity. The 'Singapore Housing Index' (SHI) is a validated, building level SES measure that bridges individual and area level measures. However, determination of the SHI has previously required periodic data purchase and manual parsing. In this study, we describe a means of SHI determination for public housing buildings with open government data, and validate this against the previous SHI determination method. Methods: Government open data sources (e.g. data.gov.sg, Singapore Land Authority OneMAP API, Urban Redevelopment Authority API) were queried using custom Python scripts. Data on residential public housing block address and composition from the HDB Property Information dataset (data.gov.sg) was matched to postal code and geographical coordinates via OneMAP API calls. The SHI was calculated from open data, and compared to the original SHI dataset that was curated from non-open data sources in 2018. Results: Ten thousand seventy-seven unique residential buildings were identified from open data. OneMAP API calls generated valid geographical coordinates for all (100%) buildings, and valid postal code for 10,012 (99.36%) buildings. There was an overlap of 10,011 buildings between the open dataset and the original SHI dataset. Intraclass correlation coefficient was 0.999 for the two sources of SHI, indicating almost perfect agreement. A Bland-Altman plot analysis identified a small number of outliers, and this revealed 5 properties that had an incorrect SHI assigned by the original dataset. Information on recently transacted property prices was also obtained for 8599 (85.3%) of buildings. Conclusion: SHI, a useful tool for health services research, can be accurately reconstructed using open datasets at no cost. This method is a convenient means for future researchers to obtain updated building-level markers of socioeconomic status for policy and research. [ABSTRACT FROM AUTHOR]

Background: The evolving pandemic of coronavirus disease 2019 (COVID-19) has become a severe threat to public health, and the workplace presents high risks in terms of spreading the disease. Few studies have focused on the relationship between workplace policy and individual behaviours. This study aimed to identify inequalities of workplace policy across occupation groups, examine the relationship of workplace guidelines and measures with employees' behaviours regarding COVID-19 prevention. Methods: A cross-sectional online survey using a structured questionnaire was conducted to gather employees' access to workplace guidelines and measures as well as their personal protection behaviours. Statistical associations between these two factors in different occupations were examined using multiple ordinal logistic regressions. Results: A total of 1048 valid responses across five occupational groups were analysed. Manual labourers reported lower availability of workplace guidelines and measures (76.9% vs. 89.9% for all, P = 0.003). Employees with available workplace guidelines and measures had higher compliance of hand hygiene, wearing masks, and social distancing, and this association was more significant among managers/administrators and manual labourers. Conclusions: Protection of the quantity and quality of employment is important. Awareness about the disease and its prevention among employers and administrators should be promoted, and resources should be allocated to publish guidelines and implement measures in the workplace during the pandemic. Both work-from-home arrangement and other policies and responses for those who cannot work from home including guidelines encouraging the health behaviours, information transparency, and provision of infection control materials by employers should be established to reduce inequality. Manual labourers may require specific attention regarding accessibility of relevant information and availability of medical benefits and compensation for income loss due to the sickness, given their poorer experience of workplace policy and the nature of their work. Further studies are needed to test the effectiveness of specific workplace policies on COVID-19 prevention. [ABSTRACT FROM AUTHOR]

Background: Many LGBTQ youth experience rejection and discrimination in their families and schools, and the range of interventions for improving their resilience and well-being is limited. We developed and piloted an LGBTQ-youth-focused intervention to build resilience and promote health equity, called Pride Camp, in an urban environment in the Midwest. Methods: Using a mixed-method approach we examined the impact of Pride Camp on resilience and other measures of well-being among LGBTQ high school students who attended camp on a college campus in 2015, 2016, and 2017. Camp attendees and the research sample included a majority proportion of transgender and gender nonbinary (TGN) youth. Results: Pre- and post-test data from our quantitative surveys (n = 28), indicated significant increases in resilience, self-esteem, and quality of life in LGBTQ youth who attended camp. Similar results were found among the TGN participants (n = 19). Qualitative data from focus groups indicated that specifically for TGN youth, the affirming environment at the camp provided social opportunities that they had not found elsewhere. Conclusions: Findings suggest that the Pride Camp intervention provides a platform for LGBTQ youth to meet peers and engage in LGBTQ communities, improving their resilience and outlook on the future. A larger controlled study of the Pride Camp intervention including measurement of additional specific health outcomes over a longer follow-up period is warranted to examine the impact of this program on health equity. [ABSTRACT FROM AUTHOR]

Background: Aboriginal and Torres Strait Islander people do not enjoy equal access to specialist health services that adequately meet their needs. Clinical genetics services are at the vanguard of realising the health benefits of genomic medicine. As the field continues to expand in clinical utility and implementation, it is critical that Aboriginal and Torres Strait Islander people are able to participate and benefit equally to avoid further widening of the existing health gap. This is the first study to explore barriers to accessing clinical genetics services among Aboriginal and Torres Strait Islander people, which has been acknowledged as a key strategic priority in Australian genomic health policy. Methods: A participatory design process engaged a majority-Aboriginal Project Reference Group and Aboriginal End-User Group. 63 semi-structured interviews were conducted with Aboriginal and/or Torres Strait Islander people who had accessed the government-funded clinical genetics service in Western Australia, Queensland or the Northern Territory between 2014 and 2018. The sample included patients, parents and carers. Participants were asked to recount their 'patient journey', from referral through to post-appointment and reflect on their perceptions of genetics and its implications for the health of themselves and their families. Analysis tracked chronological service engagement, followed by an inductive thematic approach. Results: Barriers to access and engagement were present at each stage of the patient journey. These included challenges in obtaining a referral, long waiting periods, limited genetic literacy, absence of Aboriginal support services, communication challenges and lack of adequate psychosocial support and follow-up after attendance. Participants' overall experiences of attending a genetic health service were varied, with positive perceptions tied closely to a diagnosis being achieved. The experience of (and expectation for) recognition of cultural identity and provision of culturally safe care was low among participants. Unaddressed concerns continued to cause significant distress in some people years after their appointment took place. Conclusions: There is significant scope for improving the care provided to Aboriginal and Torres Strait Islander people at clinical genetics services. Immediate attention to minimising logistical barriers, developing relationships with Aboriginal Community Controlled Health Services and providing practical and specific cultural safety training for practitioners is required at the service-level. Our findings strongly support the development of guidelines or policies recognising the collective cultural needs of Aboriginal and Torres Strait Islander people in relation to genomic health care. [ABSTRACT FROM AUTHOR]

Background: There are inequalities in breastfeeding initiation and continuation rates, whereby socio-economically disadvantaged mothers are least likely to breastfeed. Breastfeeding peer support (BPS) interventions are recommended as a solution, and in the UK non-profit organisations are commissioned to deliver BPS services in areas of socio-economic deprivation. BPS interventions have a mixed evidence base, offering limited knowledge about the interaction between context and intervention and how this affects women's experiences. Methods: This interpretive study used a case study methodology to explore how and why two BPS services developed their services in socio-economically deprived contexts. Methods aimed to generate holistic understanding of BPS service development. Data collected across both cases comprised; observation (n = 1), and semi-structured interviews with: mothers who had (n = 10) and had not (n = 9) engaged with the BPS services, peer supporters (PSs) (n = 9), community health professionals (n = 5), infant feeding co-ordinators (n = 2), non-profit organisation managers (n = 3), and public health commissioners (n = 2). Inductive grounded theory analytic techniques of open coding and constant comparisons, followed by cross case comparisons, were used to analyse the data. Results: The over-arching theme - 'the transcending influence of society' – offers insights into the underlying context and drivers impacting service development. It reflects how funding and data sharing arrangements determined service operation and the peer's access to women. Four underpinning themes explain how: peer supporters were resourceful in adapting their services ('adapting and modifying the support'); BPS organisations worked to enable women's access to supportive breastfeeding environments, but did not necessarily focus service development on the needs of women living in areas of deprivation ('supporting women's journeys to access'); the BPS-professional connections for supporting access and how BPS could result in more supportive community environments ('embedding within healthcare practice'); and how management practices precluded meaningful use of data to provide context led service development ('ways of using knowledge'). Conclusions: Findings suggest that while PSs are commissioned to focus on those most in need, there is limited discussion, collection, or use of knowledge about women's lives to develop needs-led service delivery. The key recommendation is the development of a social ecological tool to facilitate the use and application of contextual knowledge. [ABSTRACT FROM AUTHOR]